Mapping Global Leadership in Child Health · Mapping Global Leadership in Child Health v Executive...
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www.mcsprogram.org
Mapping Global Leadership in
Child Health
Authors: Mary E. Taylor, Renata Schumacher, and Nicole Davis
Acknowledgments
The Maternal and Child Survival Program (MCSP) is a global, United States Agency for International
Development (USAID) Cooperative Agreement to introduce and support high-impact health interventions
with a focus on 24 high-priority countries with the ultimate goal of ending preventable child and maternal
deaths within a generation. The program is focused on ensuring that all women, newborns, and children—
especially those most in need—have equitable access to quality health care services. MCSP supports
programming in maternal, newborn and child health, immunization, family planning and reproductive
health, nutrition, health systems strengthening, water/sanitation/hygiene, malaria, prevention of mother-
to-child transmission of HIV, and pediatric HIV care and treatment. Visit www.mcsprogram.org to learn
more.
This report is made possible by the generous support of the American people through USAID under the
terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the
MCSP and do not necessarily reflect the views of USAID or the United States Government.
We the authors (Mary E. Taylor, Renata Schumacher, and Nicole Davis) and the Child Health Team
would like to thank those people who generously shared their knowledge, experience, and ideas about
child health during in-depth interviews and other consultations for this study. We would also like to thank
the study’s advisory committee for providing guidance on study design and methods and feedback to
findings, conclusions, and recommendations. We would like to extend special thanks to Grace Chee,
leader of the Health Systems Strengthening Team, and Cara Sumi, senior program associate of
MCSP/Results for Development (R4D), who conducted the review of child health financing and prepared
those sections of the report. Finally, we would like to thank the staff of MCSP who added expert
perspective and much-needed logistical support. Report completed April 2016.
Advisory Committee Members
Jerome Pfaffman
UNICEF
Kerry Ross
USAID
Malia Boggs
USAID
Dr. Mariam Claeson
Bill & Melinda Gates Foundation
Dr. Mark Young
UNICEF
Dr. Michel Pacqué
Maternal and Child Survival Program
Dr. Samira Aboubaker
WHO
Maternal and Child Survival Program Contributing Members
Anna Bryant
Dr. Dyness Kasungami
Patricia Taylor
Robert Steinglass
Dr. Serge Raharison
Mapping Global Leadership in Child Health i
Contents
Acknowledgments
Abbreviations ................................................................................................................................ iii
Executive Summary ...................................................................................................................... v
Introduction and Study Background ........................................................................................... 1
Study Questions ............................................................................................................................................................ 1
Methods and Analysis ................................................................................................................................................... 1
Limitations....................................................................................................................................................................... 3
Findings: Child Health Issue Characteristics .............................................................................. 4
Severity of the Child Health Problem ...................................................................................................................... 4
Perceptions of Severity of the Child Health Problem .......................................................................................... 6
Effectiveness of Solutions (Tractability) ................................................................................................................... 7
Perceptions of Effectiveness of Solutions ................................................................................................................ 8
Importance of Children as an Affected Group ...................................................................................................... 9
Findings: Framing of Child Health ............................................................................................. 10
Findings: Momentum for Child Health ..................................................................................... 10
MDGs and SDGs ......................................................................................................................................................... 11
IMCI and iCCM ............................................................................................................................................................ 12
Pneumonia and Diarrhea ........................................................................................................................................... 12
Findings: Factors That Affected Momentum ........................................................................... 14
Contextual Factors: Competing Priorities ............................................................................................................ 14
Health System Platforms and Scaling Up ............................................................................................................... 14
Country Ownership and Leadership ...................................................................................................................... 15
The Success of Child Health ..................................................................................................................................... 15
Findings: Stakeholders, Initiatives, and Coordination ............................................................. 16
Organizations ............................................................................................................................................................... 16
Initiatives and Groups ................................................................................................................................................ 18
Leaders .......................................................................................................................................................................... 20
A Note on the Lancet ................................................................................................................................................. 20
Coordination of Work in Child Health ................................................................................................................. 21
Findings: Political Commitment and Funding .......................................................................... 23
Political Commitment ................................................................................................................................................ 23
ii Mapping Global Leadership in Child Health
Conclusions: Advancing Child Health ....................................................................................... 24
The Future Environment ........................................................................................................................................... 24
Effectiveness of Child Health Networks................................................................................................................ 26
Child Health Issue Characteristics .......................................................................................................................... 26
Child Health Network and Actor Features .......................................................................................................... 27
Child Health Policy Environment ............................................................................................................................ 28
Recommendations ...................................................................................................................... 29
Reframing Child Health and Communicating It ................................................................................................... 29
Re-establishing Leadership ........................................................................................................................................ 29
Reversing Fragmentation and Coordinating Effectively ..................................................................................... 29
Data and Accountability ............................................................................................................................................ 30
Country-Level Focus .................................................................................................................................................. 31
Appendix A: Methodology Details ............................................................................................. 32
Appendix B: Instrument ............................................................................................................. 36
Appendix C: Desk Review of Lessons Learned ......................................................................... 39
References .................................................................................................................................... 49
Mapping Global Leadership in Child Health iii
Abbreviations
AFRO African Regional Office
ALMA African Leaders Malaria Alliance
APR A Promise Renewed
ARI acute respiratory infection
AU African Union
BASICS Basic Support for Institutionalizing Child Survival
BMGF Bill & Melinda Gates Foundation
C-IMCI Community Integrated Management of Childhood Illness
CARMMA Campaign on Accelerated Reduction of Maternal, Newborn, and Child Mortality
CCM community case management
CDD control of diarrheal disease
CHAI Clinton Health Access Initiative
CHERG Child Health Epidemiology Reference Group
CHW community health worker
CIDA Canadian International Development Agency
CMH Commission of Macroeconomics and Health
CSO civil service organization
DFATD Department of Foreign Affairs, Trade and Development
DFID Department for International Development
DPT diphtheria-tetanus-pertussis
DPWG Diarrhea Pneumonia Working Group
ENAP Every Newborn Action Plan
EPCMD Ending Preventable Child and Maternal Deaths
EWEC Every Woman Every Child
G8 Group of Eight
GAPP Global Action Plan for the Prevention and Control of Pneumonia
GAPPD Integrated Global Action Plan for the Prevention and Control of Pneumonia & Diarrhea
GATS General Agreement on Trade in Services
GF Global Fund
GFATM Global Fund to Fight AIDS, TB, and Malaria
GFF Global Financing Facility
GHP global health partnership
GPEI Global Polio Eradication Program
HiB Haemophilus influenzae type b
HMM home malaria management
HSS health systems strengthening
HSS/E health systems strengthening and equity
IDA International Development Association
IHME Institute for Health Metrics and Evaluation
iCCM integrated community case management
IMCI integrated management of childhood illness
LMIC low- and middle-income countries
M&E monitoring and evaluation
MCH maternal and child health
MCHIP Maternal and Child Health Integrated Program
MCSP Maternal and Child Survival Program
MDGs Millennium Development Goals
MH maternal health
MNCAH maternal, newborn, child, and adolescent health
MNCH maternal, newborn, and child health
iv Mapping Global Leadership in Child Health
MOH Ministry of Health
NGO nongovernmental organization
NORAD Norwegian Agency for Development Cooperation
NPO nonprofit organization
ODA official development assistance
OECD Organisation for Economic Co-operation and Development
ORS oral rehydration salts
ORT oral rehydration therapy
PEPFAR President’s Emergency Plan for AIDS Relief
PMI President’s Malaria Initiative
PMNCH Partnership for Maternal, Newborn, and Child Health
R&D research and development
RBM Roll Back Malaria
RMNCAH reproductive, maternal, newborn, child, and adolescent health
RMNCH reproductive, maternal, newborn, and child health
SDGs Sustainable Development Goals
SSA sub-Saharan Africa
SUN Scaling Up Nutrition
SWAPs sector-wide approaches
SWOT strengths, weaknesses, opportunities, and threats
TA technical assistance
U5M under-5 mortality
U5MR under-5 mortality rate
UHC universal health care
UN United Nations
UNFPA UN Population Fund
UNSG UN Secretary-General
USAID United States Agency for International Development
WV World Vision
Mapping Global Leadership in Child Health v
Executive Summary
The aim of this study was to better understand both the evolution of child health as a global health issue
since the year 2000 as well as its network of stakeholders and leaders. Building on this understanding, we
explore how leadership might be strengthened and child health repositioned by the community to attain
better outcomes in the current time period. For the study, we reviewed published literature and other
reports on global child health policy, child health programs, funding, and global health partnerships. We
also conducted over 30 in-depth interviews of child health experts and stakeholders from donors,
development partners, and nongovernmental organizations. Data were analyzed by evaluation question
and aligned with a framework on the effectiveness of global health networks first proposed by Shiffman.1
The Future Environment
Effective strategizing for the advancement of child health over the next several years is at a critical
juncture. There are several important features of the evolving global context that emerged from interviews
and documents:
The level of uncertainty for development support is high in the near term, due to the major shift in
global goals and strategies, the refugee crisis in Europe, other humanitarian crises including fragile
states, and impending changes in leadership of institutions key for child health.
The implications of the shift to the Sustainable Development Goals (SDGs) for health and/or children
are still emerging, but priorities, political commitment, and likely funding will be more broadly
distributed and possibly with less clarity of purpose. If any of these resources are “zero-sum,” child
health (other than immunization) is likely to be working with less.
The World Bank has heightened its presence in reproductive, maternal, newborn, child, and
adolescent health (RMNCAH) with the Global Financing Facility (GFF). There is political reliance
on the GFF to finance and rationalize financing of child health, especially those components not
financed through GAVI or the Global Fund. However, there is a high level of uncertainty about its
potential effectiveness.
The high-level core architecture for child health (and RMNCAH more broadly) is emerging. It will be
very important to track the place and priority of child health within this architecture.
Conclusions
Improved child health remains an important aspiration at the global level, but it does not currently hold a
position of prominence nor can it count on sufficient commitment to meaningfully advance or transform
the agenda to reach the vision for 2030. This time period is a turning point and provides a good
opportunity for child health advocates to make changes that enhance progress.
Child Health Issue Characteristics
Child health has been a central pillar of global health for many years and is still an important part of the
vision for the future. Children as a group are valued, and this should continue to resonate publicly; but
this strength has not been tended to adequately.
During the Millennium Development Goals (MDGs) era, the reduction of child mortality was widely
recognized as a stunning success, but this has come at the cost of the perception that the job has been
finished. The truth is that there are still many preventable deaths of children, and inequalities are
pervasive; but this is not broadly recognized outside the child health community.
1 Shiffman, Quissell, Schmitz, et al. (2015).
vi Mapping Global Leadership in Child Health
Globally, it is believed that immunization and malaria programs have had more impact than pneumonia
and diarrhea interventions. In the first decade of the 2000s, the child health community placed a big bet
on the integrated management of childhood illness (IMCI) as the best approach to the management of sick
children. However, while IMCI was conceptually sound, problems emerged with the complexity and scale
of implementation needed. This hindered the spread of the pneumonia and diarrhea interventions that
might have prevented more deaths and, along with other factors, contributed to the current gaps in
coverage.
Child Health Network and Actor Features
Leadership is essential for maintaining and rebuilding the momentum of child health. People interviewed
for this study uniformly reported that for the past 20 years (since James Grant’s tenure at UNICEF), no
effective, individual global champion for child health has emerged. Further, it is not clear that new
effective champions are developing from the next generation of child health proponents. Similarly, in the
past 15 years, there has been weak or disinterested leadership exhibited by global organizations with
mandates for child health.
With what appears to be a more mindful and decisive shift of locus of health development action to
countries, country leadership—which has always been important—is now critical. High-level political
decision makers in countries, who may or may not have the requisite technical background, are central to
achieving impact in child health. The future is not about others doing more in countries, but countries
directing and doing more themselves with the resources that can be brought to bear.
At certain time periods during the last 15 years, there was momentum for child health in pursuit of MDG
4: Reduce Child Mortality. However, this momentum has not transitioned through to the SDGs. Perhaps
no health issue has yet transitioned, but the child health community urgently needs to find effective ways
of mobilizing support that builds on the SDG concept and focuses attention on children for the next 5–10
years. A Promise Renewed (APR) (and Ending Preventable Child and Maternal Deaths [EPCMD] for
USAID, internally) has helped consolidate strategy for some, but its potential role and future seem
limited.
Child health has become increasingly fragmented and siloed as a field and within organizations. It has
been divided into diseases, population subgroups, and intervention packages that rarely come together and
are often juxtaposed. This contributes to competition and is reinforced, sometimes unintentionally, by the
decisions and actions of donors and development partners in supporting subgroups. Similarly, child health
has become less visible within key organizations. It is increasingly separated from maternal and newborn
health, especially with the prevailing focus on childbirth and the time around delivery. In part, this
fragmentation explains the lack of a unified and compelling child health vision.
Since the 1980s, there have been affinity or working groups that have brought together experts and
practitioners around specific technical topics for child health—for example, the integrated community
case management (iCCM) Task Force and the Diarrhea and Pneumonia Working Group (DPWG). These
have been convened by multiple organizations and have served to pool information; build consensus on
evidence, guidelines, and measurement; publish information; and sometimes coordinate action. These
groups have shown mixed effectiveness and have generally not served to leverage their influence across
disciplines or raise the profile of child health. It is important that expectations of influence be matched to
their purpose.
In the post-MDG world, child health needs to be reframed. Future child health framing should start with a
holistic approach to all aspects of child health (newborns and infants and children together) and contain a
more explicit expression of equity, because without it mortality will not reach targets. Health systems and
platforms need to be addressed, focusing on commodities, health workers, and quality, including all levels
Mapping Global Leadership in Child Health vii
from the community to the hospital and the linkages between them. Flexibility will be a necessary feature
of health systems so that delivery can be rapidly adapted to local contexts to respond to need.
The greatest challenge with reframing is one of communication and resonance with audiences that wield
or will wield influence and power. Ending preventable deaths, on which the community now relies, is not
sufficient because it appears, based on feedback collected for this study, to lack compelling resonance.
Child Health Policy Environment
There were consonant expectations of what should be addressed in child health driven by a common,
measurable goal (MDG 4), unified by the Bellagio Child Survival Group and pinpointed in the Lancet in
2003. This was later reinforced by Every Woman Every Child (EWEC) and APR, although there were
variable expectations and fragmented support for how to deliver proven interventions that met child
health needs. Now, post-MDGs, it is not clear that there is a holistic view of strategies to address
priorities and provide support for child health programs, despite published syntheses on current disease
burdens and the unfinished agenda.
In the early part of the decade after 2000, polio eradication and well-funded global partnerships like
GAVI competed for child health resources, and there is worry that they may capture a disproportionate
portion of resources in the next five years. Development assistance for health has increased since 2000 for
newborn and child health, although it has not increased as sharply as for immunization and polio. Since
2009, newborn and child health funding has grown faster than other health programs such as those for
HIV, malaria, or tuberculosis (TB), but from a relatively lower base. This demonstrates that important
financial commitment exists for child health even though the future is less certain. Combined with the
potential for the GFF to influence spending in countries, there may be a window of opportunity to
improve child health support; but it will behoove the child health community to track what happens
closely and respond quickly.
As the world and global health turn forward to 2030, this is a time of high uncertainty for child health.
Such times may be viewed both as a threat and as an opportunity. Either way, what will be required is a
community more highly attuned to windows of possibility, the will to take advantage of them, and the
structure to collaborate.
Recommendations
What should the global child health community do to make sure that the full range of child health issues
are at the forefront of the global health landscape?
Reframing Child Health and Communicating It
How should child health be framed, both strategically and substantively, to reflect the realities of 2016?
Recommendation 1: With the shift to the SDGs, child health should be deliberately reframed so that it
emphasizes the value of children, a more holistic approach including “newborns and infants and children”
as one, and a clear aim for equity.
In addition to the reframing, it is equally important that resources be applied to crafting how the framing
is communicated more effectively than the current messaging. Communications probably need to evoke
the value of children as a driver for ending preventable death.
Reestablishing Leadership
Who has the stature to lead, and what does the global child health community need to do (and avoid) to
support this leadership?
viii Mapping Global Leadership in Child Health
Recommendation 2:
a) The principal global partners in child health need to come to agreement on and then designate and
support a lead organization to consistently provide overall messaging for child health.
b) They also need to seek and nurture over time one or several credible champions who will speak
powerfully for child health on the global stage.
The organization could be drawn from any of the major ones highlighted later, but it needs to have
legitimacy, be positioned in the emerging architecture, and be able to be heard by all actors. Once
designated, it needs to be decisive in its prioritization of child health and other organizations need to be
clear in their public support. Similarly, child health must have new champions at high levels. Without
this, commitment to child health will continue to falter.
Reversing Fragmentation and Coordinating Effectively
How should child health stakeholders (organizations and initiatives) align and advance collaboratively
toward goals?
Recommendation 3: Key stakeholders need to create and implement a shared strategic approach for:
a) Raising the visibility of child health as a whole rather than in subcomponents
b) Ensuring a strong child health voice in Strategy 2.0, SDG3 monitoring, and the GFF
c) Bridging child health components of existing strategies across institutions in such a way that country
action is more likely
In addition, investments should support collaboration and explicitly dis-incentivize fragmentation within
child health.
There are multiple strategies that incorporate child health that were recently launched globally (EWEC
2.0, UNICEF, World Health Organization [WHO], EPCMD, etc.). All of these strategies embrace a
continuum of care, some more broadly than others; so the challenge is to promote the common core for
child health with a recognizable and compelling voice. It is not yet clear what such a strategic approach
should look like or what actionable milestones are really needed (analogous to what the Every Newborn
Action Plan [ENAP] is for newborn health), but it starts with child health advocates coming together to
create a way forward. That way forward should build on what has been learned from the Call to Action,
APR, and similar efforts in maternal and newborn health. New child health framing might also suggest
new or re-emerging alternatives.
Recommendation 4: Focus on a few key coordinating mechanisms for child health and support their
performance appropriate to objectives, roles, and participants. Close those that do not provide enough
value at both global and country levels.
There are multiple coordinating mechanisms and venues for child health at all levels. Some are given—
the Partnership for Maternal, Newborn and Child Health (PMNCH), GAVI, Global Fund, EWEC, and so
on. For these, the child health community should assess potential benefits and costs, then work with them
accordingly. Similarly, technical or thematic affinity groups may be useful for learning but should focus
on a clear or limited purpose with right-sized support. There is likely a need to revitalize a small, cross-
organization group of committed, high-level child health advocates to re-establish a strong voice in this
space.
The stakeholder environment for global health is more crowded and complex than it was five years ago,
and there are many coordination mechanisms at multiple levels. Going forward, the most important place
to get coordination right is at the country level.
Data and Accountability
How will the child health community know there is progress and hold stakeholders accountable?
Mapping Global Leadership in Child Health ix
The Countdown reporting and accountability process worked reasonably well to build commitment to
child health during the MDGs. There are three linkages in the SDG architecture that the child health
community will need to make to continue to leverage this function. The first is the Independent
Accountability Panel within the PMNCH that replaces the Commission on Information and
Accountability. The second will be the next version of a Countdown-type mechanism that is under
development now. The third is the Monitoring & Evaluation Reference Group hosted by WHO, which is
likely to focus on measurement of maternal and newborn health in the near term.
Recommendation 5: Ensure that child health data and information are well represented, packaged, and
reported within the context of the emerging evaluation groups.
Country-Level Focus
By far, the strongest finding that emerged from this study was acknowledgment of the shift of locus for
transformation and sustained action from the global to the country level. While there have been many
statements over the years and more effort recently to ensure country partnership, country leadership, and
country investment, there appears to be more commitment to making it happen. The success of the GFF
depends on it. The country should be part of the reframing of child health.
Recommendation 6: Reframe child health with the country at the center and engage differently with
countries with weaker systems and leadership to sustainably improve child health. Invest in tracking and
learning from the process.
It is apparent that countries with strong leadership will themselves direct how child health will improve
and how global or regional partners will engage with them to do it. This does not appear to be a matter of
contention, and donors appear to be increasingly willing to support strong country leadership. The
challenge is how best to address countries with weak leadership, which continue to be numerous.
Development partners will need to explicitly and in coordination with each other determine whether
investing in stronger country ownership and national health systems warrants the risk of slower progress
in achieving health targets. This is a fundamental policy decision that must be reached with a clear
understanding of specific country realities and should not be applied as a blanket policy across all
countries. The reality is that some countries will respond to this stimulus by moving to meet the
challenge, albeit slowly, while others may use flexibilities to act on agendas far removed from the SDG
child health goals. Investing in tracking and learning about how and why this happens will be critical.
This process is likely to be the single largest challenge facing the global child health support community
over the next 15 years.
x Mapping Global Leadership in Child Health
Mapping Global Leadership in Child Health 1
Introduction and Study Background
The aim of this study was to better understand both the evolution of child health as a global health issue
since the year 2000 as well as its network of stakeholders and leaders. Building on this understanding, we
explore how leadership might be strengthened and child health repositioned by the community to better
attain outcomes in the era of ending preventable deaths and the Sustainable Development Goals (SDGs).
The study was funded by USAID and conducted by a three-person team guided by an advisory committee
of representatives from USAID, UNICEF, WHO, the Bill & Melinda Gates Foundation, and the MCSP.
Study Questions
What are the current global leadership groups, initiatives, and forums for all elements of child health?
By whom are these currently led? How are these currently led and coordinated?
What were the major lessons learned about other past and current global health leadership efforts that
might inform moving the child health agenda moving forward?
What strategies were employed to move the child health agenda forward? What factors shaped the
movement of this agenda? How did the strategies and factors (e.g., using health-related MDGs,
SDGs, IMCI, iCCM, and pneumonia-diarrhea as “tracer” themes) interact over time to move the
agenda forward?
What overall financial resources have been made available for child health since the year 2000?
How can global child health leadership be structured to best support the improvement of child health
outcomes going forward? How could or should global child health forums relate to, engage, and work
with regional institutions and countries?
Methods and Analysis
The study employed two methods of data collection including desk review and semistructured in-depth
interviews. Core areas of child health (IMCI-iCCM, MDGs-SDGs, pneumonia-diarrhea) were reviewed to
document programs and results over the time period 2000 to 2015, and a stakeholder analysis was
conducted.
The desk review of published literature included global child health policy, child health interventions and
programs with an emphasis on immunization, MDG 4–SDG 3, IMCI–iCCM, pneumonia-diarrhea, child
health service delivery strategies, and reviews of other global health partnerships and networks. Data were
also extracted from child health–related organization and initiative websites and from existing health
financing databases. Over 120 published references were reviewed and approximately 40 websites visited.
A series of 33 in-depth interviews were conducted with professionals knowledgeable about child health
globally or about sub-Saharan Africa contexts (for interview instrument, see Appendix B). Potential
respondents were suggested by advisory committee members, child health–related working group
membership lists, and other organizations. The final list was selected to represent type of organizational
affiliation, qualification, area of expertise, and length of time engaged with global child health. Interview
data were entered, coded, and excerpted in Dedoose, a web-based qualitative data analysis platform.2
2 Dedoose Version 6.1.18 (2015).
2 Mapping Global Leadership in Child Health
Table 1: Number of interviewees based on type of organization
Type of organization Number interviewed (33)
Multilaterals and global partnerships 10
Bilateral organizations 6
Foundations 4
Academic institutions 1
Nongovernmental organizations 6
Private sector 1
Sub-Saharan Africa region 5
Excerpts were analyzed by code and aggregated into themes. Tracer interventions were assembled into
timelines or chronologies (2000–2015) using data from both the desk review and interviews. A strengths,
weaknesses, opportunities, and threats (SWOT) analysis was done for stakeholders organized into two
groups including organizations and initiatives/forums. Individually named leaders were also tallied.
The findings for the child health financing section primarily rely on Institute for Health Metrics and
Evaluation (IHME) data, with disaggregation based on data availability. Based on a review of existing
data sources, the IHME dataset was selected as it provided the most comprehensive data over the time
period of interest. IHME data for child health include newborn health and immunization. Where possible,
immunization funding data have been reported separately, but the data do not allow complete
disaggregation. Newborn funding was too difficult to disaggregate systematically, so it is not possible to
distinguish relative changes in neonatal versus postneonatal funding.
Data from all sources were used to triangulate answers to study questions and aligned with a framework
on the emergence and effectiveness of global health networks to better understand child health networks
and their influence.3 This framework is illustrated below; qualitative data were coded and literature data
aligned to the subcategories for network and actor features, policy environment, and issue characteristics.
More information on the methodology can be found in Appendix A.
3 Shiffman, Quissell, Schmitz, et al. (2015).
Mapping Global Leadership in Child Health 3
Figure 1: Framework on the emergence and effectiveness of global health networks
Table 2: Network emergence and effectiveness are more likely if . .
Issue Characteristics
Severity Problem is perceived to have high mortality, morbidity, or cost
Tractability Solutions are perceived to exist and are not controversial
Affected groups Group is easy to identify and viewed sympathetically
Network and Actor Features
Leadership Capable, well-connected, respected champions exist
Governance There are appropriate governing structures able to facilitate collective action
Composition Diverse actors are involved and well linked (creativity)
Framing strategies Issue is positioned so that it resonates, especially with political elites
Policy Environment
Allies/opponents Groups interests are aligned
Funding Donor funding is available and applied
Norms It is an issue that many expect will be addressed
Findings from the study are organized into the characteristics of child health as an issue; how child health
has been framed in the past 15 years; how MDGs, IMCI, and pneumonia-diarrhea programs affected
momentum; what helped or hindered from the perspective of study participants, leaders, and stakeholders;
how efforts were affected by coordination, political commitment, and funding; and what initiatives
represent the best way forward. If the source is from an interview, it is put in italics and a blue text box
and is coded by organization type. The report draws assumptions from the literature review, interviews,
and other research to produce broad recommendations to global stakeholders and the child health
community as a whole.
Limitations
This study should be considered a first step in developing a deeper understanding of child health
leadership, networks, and prominence. A significant gap is that it was not possible under the time
4 Mapping Global Leadership in Child Health
constraints to interview country-level stakeholders who may be the most important part of the child health
network, especially going forward. Only a limited perspective emerged from the sub-Saharan Africa
regional level, given the small number of interviews possible, and without country perspective there was
insufficient information to form conclusions about the region. Similarly, there was little information
captured about the private sector. Most of the interviews were conducted with people at upper-mid levels
of organizations. This may limit the study’s high-level policy or political perspective, especially at the
global level. Within the study constraints, it was not possible to preview early conclusions or
recommendations with expert groups or to conduct follow-up interviews to more deeply consider framing
issues or the role of power.
Findings: Child Health Issue Characteristics
Severity of the Child Health Problem
The decline in child mortality since 1990 has been a remarkable success story. Globally, from 1990 to
2015, the number of children under five who died in a year dropped from 12.7 million to 5.9 million, even
though the number of children in this age group increased 4.3% in the same time period. The under-five
mortality rate (U5MR) dropped 53% and the annual rate of decline accelerated from 1.8% (1990–2000) to
3.9% (2000–2015). Sixty-two of 195 countries achieved MDG 4, although disparities remain such as for
sub-Saharan Africa, which continues to have the highest U5MR in the world (Figure 2). In contrast,
neonatal mortality has declined much more slowly, from 36 to 19 deaths per 1,000 live births between
1990 and 2015 (Figure 3), and represents 45% of global child mortality now (Figure 4). Neonatal
mortality was reduced by 47% in this time period while postneonatal mortality declined 58%. However, it
is important to note that in sub-Saharan Africa, 60% of child mortality still happens in the postneonatal
period and is largely preventable.4 In sub-Saharan African countries with the highest number of under-
five child deaths (Nigeria, the DRC, and Ethiopia) non-newborn deaths represent 67% of all under-five
mortality (Figure 5).
Figure 2: U5MR for developing regions and SSA, 1995–2015
4 UNICEF. Levels and Trends of Child Mortality: Report 2015. IGME. UNICEF, September 2015, p. 1.
Mapping Global Leadership in Child Health 5
Figure 3: Neonatal mortality rate for developing regions and SSA, 1995–2015
Figure 4: Causes of death for children under five years, 2015
As substantial progress in reducing child mortality was achieved in the last decade, differences in equity
of progress between and within countries became more apparent. Dimensions of these inequities are
complex and can include economic status, geographic location, parents’ education level, urban or rural
residence, ethnic group, and gender. For example, almost 9 out of 10 deaths to children under five occur
in low- and lower/middle-income countries, and children from the poorest households in those countries
are 1.9 times more likely to die than children from the richest households.5 Children thus continue to die
in large numbers from preventable causes, more so if they are disadvantaged by the conditions in which
5 UNICEF (September 2015).
6 Mapping Global Leadership in Child Health
they live. Attention to this must be maintained, especially if the SDG under-five mortality target of 25 per
1,000 live births is to be attained by 2030. “Child survival should remain at the heart of global health and
development goals.”6
Figure 5: Under-five and neonatal mortality rate (per 1,000 live births) and non-newborn deaths vs.
under-five deaths (note that the size of the bubbles is proportional to the number of deaths)
Perceptions of Severity of the Child Health Problem
Perceptions of the impressive decline in child mortality overshadow concerns looking forward. The size
and rates of reduction that were experienced since 2000 have contributed to a sense that the job is done
and whatever is needed will continue on its own.
There is a complacency that we’ve done the job with child health and that we need to move on to newborn
health and maternal mortality and family planning. (Foundation, global)
This perception is reinforced by a growing sense of urgency that the health of newborns must be
addressed to have overall mortality impact for children. The newborn health network has been very
effective at raising attention, although resources it has garnered may not be sufficient to address the
problem.7 Through the ENAP process and as part of SDG 3 elaboration, this attention has been further
narrowed to the time around delivery, shifting attention away from child health–oriented platforms of care
delivery to maternal health–oriented platforms.
6 Bryce, Victora, and Black (2013). 7 Shiffman (2015).
Mapping Global Leadership in Child Health 7
Imbalances are driven by groups—we’ll get our agenda served through women. So that’s the first day of life, but
it is completely inadequate. We are still in this situation where there is not very holistic thinking about child
health. (Academic, global)
There also appears to be a lack of understanding or sense of urgency about common child illnesses that
are killers, especially pneumonia and diarrhea. While proven interventions exist for both, coverage of
effective treatments (oral rehydration salts [ORS] and zinc for diarrhea, antibiotics for pneumonia) have
increased only slowly, especially at the national scale. Finally, nutrition has begun to be more seriously
addressed as a major contributor, but resources still lag as the numbers of children at risk increase.
People to this day are amazed that pneumonia is the single largest infectious disease killer. (Multilateral, global)
The inequity of intervention coverage and outcomes was frequently identified as a major challenge to
further progress in child health. What quickly became clear from respondents is that “equity” and the
problems that are assumed to cause it are viewed differently by stakeholders. For example, some measure
“equity” by geographic access to health care; others use household economic status or social
marginalization or vulnerability. Despite the fact that measures for child health under SDG 3 include
reporting by wealth quintiles, there is no common articulation of aim or strategy for equity that would
guide programs or policies.
We talk about the issue of equity and it’s well documented that some segments of society are much more apt to
be users . . . but we don’t seem to have very clearly articulated strategies for reaching those other groups; and
even if we do, we don’t have good data for knowing whether or not we are achieving it. (NGO, global)
Effectiveness of Solutions (Tractability)
Over the past 25 years, considerable evidence on the effectiveness of child health interventions has been
generated.8 These proven, low-cost interventions have been standardized and adapted to countries, and
efforts have been made to deliver them either vertically or in packages in facilities and at the community
level.
A turning point was marked in 2003, when the Lancet published the first child survival series that
synthesized and communicated the effectiveness of these interventions to policy makers and technical
leaders. As a result, the child survival community coalesced around a common approach aimed at
increasing the coverage of high-impact interventions in countries. As noted in one study, “The series
sought to call the UN agencies to task by highlighting evidence that progress in reducing child mortality
had slowed and in some cases reversed . . . the Lancet 2003 series aimed to make child survival an
international health priority once again and attract the resources needed to accelerate the reduction of
child mortality.”9
The evidence base pulled together in the Lancet child survival series really helped to focus people’s priorities on
those interventions that were shown to be effective. (Multilateral, global)
In 2005, building on the Lancet series, the Countdown to 2015 was set up to serve as an independent
accountability mechanism for monitoring country progress on MDGs 4 and 5. Since then, the Countdown
has compiled mortality and high-impact intervention coverage data for about 75 countries on a biannual
8 Black, Morris, and Bryce (2003). 9 Díaz-Martínez, Elisa, and Elizabeth D. Gibbons. “The Questionable Power of the Millennium Development Goal
to Reduce Child Mortality.” Journal of Human Development and Capabilities 15, no. 2–3 (July 3, 2014): 203–17.
doi:10.1080/19452829.2013.864621.
8 Mapping Global Leadership in Child Health
or annual basis. These data have been used to demonstrate progress and advocate for prioritization and
resources. In 2015, the Countdown reported on the broad patterns that emerged from looking at changes
in coverage during the MDG era:
“Key malaria and HIV interventions began at low coverage and increased markedly.
Some interventions with high coverage in 2000 increased only modestly, partly because there was
limited scope for increase (antenatal care 1 visit, three vaccines [DPT, HiB, measles]). However, a
substantial proportion of the gap was closed for these interventions.
All other interventions studied had coverage below 60% before 2009 and increased 10 percentage
points or less (family planning, antenatal care 4+, skilled birth attendants, exclusive breastfeeding,
case management of diarrhea and pneumonia.)” 10
Other observers went on to say, “These patterns suggest that rapid coverage increases are possible when
interventions are prioritized and sufficiently funded, as for malaria or HIV. However, there was very
limited progress for interventions that require multiple service contacts along the continuum of care or
access to care 24/7, particularly during pregnancy and childbirth, and for the management of childhood
diarrhea and pneumonia.”11
As the global dialogue has moved from MDGs to SDGs, there has been more consideration of distal
determinants of child mortality and multisectoral contributions to improved health. Some argue that gains
in child survival were really driven by economic growth and that attention should focus there.
For those countries who reached MDG 4 in the middle of 2014, looking at what has contributed to U5MR—half
of that was the impact of specific interventions but the other half was all kinds of other things. For example,
education, infrastructure, water, sanitation and women’s empowerment. (Foundation, global)
Perceptions of Effectiveness of Solutions
Perceptions of the effectiveness of solutions to reduce child mortality align with available data.
Respondents identified immunization and malaria interventions as extremely effective at scale.
Immunization has moved quickly because of the addition of new vaccines, and the widespread
distribution of bed nets for the prevention of malaria has led to high levels of use. The organizations or
alliances that lead investment and programming in both of these areas—GAVI, the Global Fund, and to
some extent Roll Back Malaria (RBM)—are seen as the most effective among global institutions.
But it was really the vaccines and the bed nets that were driving a lot of that success, which means that
institutions like GAVI and the Global Fund have really contributed massively to child health gains under the
MDGs. (Multilateral, global)
Interventions that address childhood pneumonia and diarrhea are viewed as having been only modestly
effective, although there are data demonstrating important reductions in cause-specific mortality for
both.12
There have been multiple approaches to service delivery starting with vertical programs before
2000, followed later by integrated strategies such as IMCI, iCCM, and Integrated Global Action Plan for
the Prevention and Control of Pneumonia and Diarrhoea (GAPPD). Case management or treatment
interventions that require increased community demand, skilled health workers, and functional logistics
10UNICEF and WHO (2015). 11 Díaz-Martínez, Elisa, and Elizabeth D. Gibbons. “The Questionable Power of the Millennium Development Goal
to Reduce Child Mortality.” Journal of Human Development and Capabilities 15, no. 2–3 (July 3, 2014): 203–17.
doi:10.1080/19452829.2013.864621. 12 UNICEF (September 2014).
Mapping Global Leadership in Child Health 9
systems for necessary supplies have proven to be difficult to scale up and thus failed to provide access to
quality care in many countries. There were reports of confusion over multiple initiatives, frameworks, and
branding of approaches that may get in the way of implementation.
Importance of Children as an Affected Group
Over the past 15 years, perceptions of the importance of child health have waxed and waned. In the 1980s
and 1990s, there was strong leadership and commitment to child survival from the child survival
revolution to universal child immunization to the “twin engines” of immunization and ORS for diarrhea.
In 2000, this was followed by the MDG declaration that was then further elaborated to MDG goals and
targets by 2002. These included MDG 4, “to reduce child mortality,” with the target of reducing the
under-five mortality rate by two-thirds between 1990 and 2015.
While child health was featured prominently in the MDGs, goal and target setting was not especially
inclusive and coincided with a strong shift of UNICEF leadership toward child rights and away from
traditional, technical health priorities. In the same time period, global attention was drawn to
immunization and HIV/AIDS with the launch of GAVI in 1999, the Global Fund in 2002, and the
President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003. The Bush administration, for example,
did not actively engage with the MDGs early on.
This began to change, as noted earlier, with the 2003 Lancet child survival series. In the mid- to late part
of the decade, the huge disparities in child mortality across the world were considered politically
unacceptable, and bilateral development agencies provided more support for immunization, ORS, and
management of sick children.
After the introduction of the Countdown, attention also focused on measurement of progress toward
MDG 4, and whether countries were “on” or “off” track. At this time, many countries were “off-track”
and there was fear that the world would not come close to reaching MDG 4. Along with the G8 Muskoka
Initiative announced in 2010,13
the Countdown helped propel the movement into Every Woman Every
Child (EWEC) and the 2010 Global Strategy for Women’s and Children’s Health.
14 In 2012, the Call to
Action15
to end preventable child deaths was made and was followed by APR.16
This elevated the
importance of child health and helped to consolidate country child health strategies, although these
initiatives brought no new resources.
And I think when we came up for air again in 2010 . . . what emerged as rebalancing was maternal and child
health—the so-called neglected MDGs. That again had broad political appeal. (Multilateral, global)
Levels of development assistance funding provide another perspective on perceptions of the importance
of child health at the global level. From 2000 to 2014, development assistance for health in newborn and
child health increased from $2.2 billion to $6.6 billion. Even if immunization and polio are removed from
these figures, newborn and child health funding increased by 44%.
We will move forward—the world will not lose its political commitment to child survival. Not the least of that is
that countries have made progress—we did pretty darn good reducing mortality by 50% so let’s keep doing it. It
feels good. (Academic, global)
13 Additional funding commitments of $7.3 billion for 5 years. 14 United National Secretary-General. 2010. The global strategy for women’s and children’s health. WHO website.
http://www.who.int/pmnch/knowledge/publications/fulldocument_globalstrategy/en/. Accessed June 2, 2016. 15 USAID (June 2012). 16 UNICEF (September 2012).
10 Mapping Global Leadership in Child Health
Findings: Framing of Child Health
After the millennium and the launch of the MDGs, improving child health was framed in terms of
tackling the leading child killers including pneumonia, diarrhea, malaria, and vaccine-preventable
diseases. This was reinforced by the use of the three MDG targets of U5MR, infant mortality rate, and
measles vaccination coverage, in contrast to the more complex and holistic framing of child health under
the earlier World Summit for Children. The framing, in terms of child death, was thought to be effective
because there was a defined starting point (even if retrospective) and most importantly a measurable
target of reducing child mortality by two-thirds. From 2000 to 2015, there was increasingly frequent
tracking of progress (“on track” or “off track”). The Countdown strengthened this framing by publishing
and comparing country progress, highlighting gaps.
Even more so since 2010, when we said that we were behind the MDGs, it really helped focus people’s minds
and brought the issue to the fore. It forces us to look at the numbers and look at the target, and where we are
from the target. (Multilateral, global)
While the perception was that MDG 4 and the specter of dying children helped build commitment, there
are differences of opinion over whether it helped mobilize resources.
We thought that by bringing up the case of how many children were dying and why they were dying, we would
be able to influence the resource allocation in country but that was not the case. (Multilateral, regional)
As EWEC and then APR were launched, the framing of child health shifted from addressing killers to
ending preventable child deaths. “Preventable” implied that health conditions are known and that they can
be taken care of with proven interventions. It also created a sense of obligation to deliver those
interventions. The “unreached” are the target and the aim is to get to them and to reap the benefits of
existing interventions. This framing builds on the success of mortality reduction and is a call to action.
Findings: Momentum for Child Health
A timeline of key events and turning points for child health is illustrated in Figure 6. This provides the
context for understanding the strategies and factors that enabled or hindered momentum and the
prominence of child health as seen through the lenses of global goals (MDGs and SDGs), IMCI and
iCCM programs, and pneumonia and diarrhea programs.
Mapping Global Leadership in Child Health 11
Figure 6: Timeline of key events and turning points for child health
MDGs and SDGs
Although they had their successes and failures, the MDG process and MDG 4 created momentum for child
health. Saving children’s lives was just, politically appealing, feasible, and with a measurable target. When
combined with Countdown, progress was visible. The UN secretary-general championed the MDGs and
development partners engaged with the process, providing funds, expertise, and intervention specifics.
There were times when progress to achieve MDG 4 floundered, lacking strong global leadership and
overshadowed by the introduction of disease-specific programs with advocates of their own. Since 2000,
MDG 4 became more prominent twice, once with the Lancet series 2003 and also at the time when EWEC
was launched in 2010. After this point, efforts were refocused on the MDG 4 endgame with considerable
publicity for those countries reaching child mortality goals early. However, the persistence of child mortality
in some countries and regions in 2015 did not appear to heighten specific global interest or stimulate action
afterward. Rather, further progress was expected to depend on improving broader programs for maternal,
newborn, and child health.
As the MDGs came to a close and work began on the SDGs, momentum for postneonatal child health
lagged. The SDGs have a much broader development perspective, and only one goal relates directly to
health and well-being. This goal covers reproductive, maternal, newborn, child, and adolescent health,
making child health less individually prominent and perceived as “better off” in terms of progress. On the
other hand, the SDGs also address underlying contributors to child death, several of which may be more
critical to improving survival given changing epidemiology and cause of death structure. Now, globally
preterm birth complications are the leading cause of death, with pneumonia second, and intrapartum
complications third (Figure 4).17
Combined with the fact that better equity is needed to lower mortality
rates, it is likely to be necessary to go beyond the vertical disease control strategies that were more
successful in child health under the MDGs.
17 Liu, Oza, Hogan, et al. (2015).
12 Mapping Global Leadership in Child Health
IMCI and iCCM
IMCI, launched in the late 1990s, was designed to address the five main causes of child mortality and to
transform the system of care for sick children. By mandate, UNICEF, WHO, and the World Bank were
positioned to help develop implementation at community, facility, and health system levels, respectively.
However, leadership changes and other priorities intervened, and IMCI was moved forward primarily
through formal guidelines and training. This led to ineffective community approaches early on, few health
system strengthening interventions, and a gold standard clinical algorithm that often proved impractical in
the field. Furthermore, interventions for pneumonia and diarrhea that had been partly successful when
vertically implemented appeared to lose ground. IMCI was consistently identified by study respondents as
the biggest disappointment in child health over the last 15 years.
[Some] treatment approaches . . . had good grounding in science and evidence but really didn’t prove to be as
powerful because programs were weak—poor training, supervision, management of drugs. IMCI and to some
degree iCCM look great on paper but functionally they are not working well. (Academic, global)
In countries, structural constraints worked against improved IMCI including staff availability, turnover,
poor supply of drugs, and competing services in busy clinics. Growing out of the realization of how
difficult and expensive scale-up was going to be, donor fatigue ensued and was reflected in diminishing
resources over time. Nonetheless, more than 100 countries adopted IMCI policies, most of which still
exist today.
We spent far too long designing customized national level guidelines for every country, which was probably the
right thing to do. But then we would spend years and tens of millions of dollars in workshop after workshop
training nurses and doctors who didn’t need to be trained. (NGO, global)
One consequence to the challenges of IMCI was the development of iCCM. iCCM targets a subset of the
most important IMCI interventions (case management of pneumonia, diarrhea, and malaria) and was put
together in a simpler package more suitable to community health systems. When supported by an existing
community platform and strong country leadership and resources, it has extended its reach. The iCCM
community has been able to leverage other sources of support, especially from the Global Fund under the
New Funding Model. However, while it may be a more effective solution for childhood illness, it is
perceived in some places as donor driven and doesn’t seem to have lent new momentum to child health at a
political level.
Pneumonia and Diarrhea
In the 1980s, the promise of ORS was used successfully by James Grant, visionary leader of UNICEF,
and others to mobilize political will and substantial resources supporting over 100 country programs; a
few demonstrated substantial declines in child mortality. However, starting in the mid-1990s through the
first decade of the 2000s, progress came to a standstill. Demand for ORS in communities stagnated
because it did not meet expectations for a rapid cure. The growth of other priorities such as malaria,
HIV/AIDS, and immunization diverted attention; diarrhea case management was absorbed into IMCI that
then operated at much smaller scale; and targeted funding disappeared. 18
Over time, more optimal ORS formulations were developed, and in 2004 WHO and UNICEF
recommended the addition of zinc to prevention and treatment protocols. The Global Zinc Task Force,
established in 2005, set out to accelerate the adoption of zinc in high-burden countries and succeeded in
attracting some political will, although the availability of zinc has been slow to materialize. In 2006, in an
18 Santosham, Chandran, Fitzwater, et al. (2010).
Mapping Global Leadership in Child Health 13
attempt to revitalize diarrhea programs, WHO, UNICEF, USAID, and Johns Hopkins University released
detailed guidelines for countries, but progress still continued at a slow pace and use rates stagnated. In
2011, the DPWG brought together efforts for both disease conditions and to support the expansion of
programs in 10 high-burden countries.
Acute respiratory infection (ARI) programs were initiated in the 1990s based on evidence from research
studies done earlier that childhood pneumonia could be assessed and treated with antibiotics in
community settings. However, compared with the early years of control of diarrheal diseases (CDD)
programs or immunization programs, they were slow to be adopted or scaled. Initially, countries thought
programs would be too difficult and too costly, given the need for antibiotics and well-supervised health
workers. Large-scale implementation of antibiotic treatment, especially at the community level, raised
concerns of appropriate use and antibiotic resistance. Programs proceeded slowly, rarely at scale. In 1995,
with the absorption of pneumonia into IMCI, attention and resources waned, as was the case with
diarrhea. For years, pneumonia was the leading cause of child death but was nearly invisible.
In the early to mid-2000s, child survival publications and mortality estimates raised the importance of
pneumonia and the potential impact of effective interventions. At this time and in parallel, GAVI and the
Gates Foundation provided support for the development of new vaccines that would prevent pneumonia
(pneumococcal/HiB). GAVI funded the PneumoADIP and the HiB Initiative aimed at country adoption of
the new vaccines. This combined effort provided new, strong momentum for pneumonia and helped
reactivate the network of pneumonia proponents.19
However, for treatment interventions, interest didn’t begin to re-emerge until 2006, when WHO and
UNICEF released “Pneumonia: The Forgotten Killer of Children.” This momentum became more
apparent in 2009 with the development of the WHO/UNICEF-led Global Action Plan for Pneumonia
(GAPP) that engaged countries through informal consultations—and with iCCM there were efforts to
expand access. At the global level, there has been increased advocacy for policy and resources by more
formal groups such as the Global Coalition Against Child Pneumonia.
The network of pneumonia actors was brought into the DPWG, and in the last two years, action plans for
both groups have been merged into the WHO- and UNICEF-sponsored GAPPD. GAPPD integrates
prevention and treatment for children and is conceptually elegant, but it is generally considered too
complex to be operationally useful.
GAPPD is an interesting framework and right way looks at prevention and treatment holistically but it went
nowhere. (Bilateral, global)
In 2015, pneumonia and diarrhea still caused 16% and 9% of deaths of children under five, respectively,
and most of this burden is concentrated in 15 countries. There has been progress in mortality reduction in
the past 15 years despite lack of cohesive political momentum, but substantial needs remain. It is not clear
yet if combined diarrhea-pneumonia efforts will build stronger support.
I think there has been modest success in some of the treatment aspects of programs including pneumonia and
diarrhea. I wish there were more but it is part of the unfinished agenda. It needs some combination of quality
care in facilities and pushing further into communities in a good number of countries. (Academic, global)
19 Berlan (2015).
14 Mapping Global Leadership in Child Health
Findings: Factors That Affected
Momentum
The following sections summarize the themes that emerged from interviews about cross-cutting factors
that affected the importance, positioning, and progress of child health.
Contextual Factors: Competing Priorities
There is ample evidence on what interventions reduce child mortality under what epidemiologic and
system conditions. This information should underpin the priorities of country health programs but often
does not; this has been a consequence of donor-driven agendas or local political decisions (e.g., polio
eradication, HIV funding in very low prevalence countries, building hospitals). In some places, it has slowed progress with preventable child mortality. Most concern was raised about the polio eradication endgame and legacy transition, especially in sub-
Saharan Africa. Disease eradication and elimination initiatives have captured the attention of politicians
and funding agencies, and the needs of the endgame may easily override the attention required to
strengthen the health systems that support child health more broadly. In addition, high levels of resources
support extra staff in large countries—in Nigeria, Ethiopia, DRC, and Chad—WHO employs 2,000 polio
staff. Simplistic notions of transferring the attention of these assets when they are no longer needed for
polio begs the question of whether they are fit for the needs of health systems or child health programs
and how they would be funded. Lastly, approximately 90% of WHO’s Regional Office for Africa biennial
immunization budgets for more than a dozen years have come from polio finances. It is unclear how this
might transition and what will be lost for child health if it does not.
In the past 15 years, child health has competed for resources with large, vertically funded programs such
as immunization, malaria, and HIV/AIDS. All three are also important contributors to child health, but
resources were often ring-fenced and controlled such that they couldn’t be used for related conditions or
population groups. At best, this was a missed opportunity and at worst it was competitive. A coherent
strategy for the whole child has no owner and is lacking in relation to other areas of child health.
A problem that the global community created, and the US government particularly contributed to, is putting
massive money into single pipelines, like PEPFAR. GAVI was funneling all the money into vaccines. So we had
these vertical programs and when you get to the country level, you have a lot of money going into single areas;
and the broader health system really struggled. (Multilateral, global)
It’s the same with donors. We have segregated out components of child health. We haven’t been able to
mobilize around comprehensive child health. (Bilateral, global)
The most uncertain threats to momentum for child health involve contextual changes that have or are
expected to have large effects on public support and levels of development aid. In 2008, when the
financial crisis occurred, fewer resources were immediately available at multiple levels, the appetite for
new initiatives waned, and interest in health systems strengthening was tabled. Similarly, the current
refugee situation in Europe has diverted attention and aid budgets from the countries in that region into
crisis management.
Health System Platforms and Scaling Up
During the 1990s, interventions for child health were labeled, managed, and implemented in a vertical,
disease-specific fashion (CDD, ARI, immunization, and vitamin A supplementation). IMCI attempted to
Mapping Global Leadership in Child Health 15
integrate service delivery but floundered. Despite the fact that integration is considered important and
studies show improved efficiency, most programs have been financed vertically, driving parallel support
systems, redundancies, and missed opportunities.
Weak community participation and low demand for formal health care have been a barrier to improved
and sustained improvements for children’s health. Community support of, demand for, and satisfaction
with core child health interventions often has not been the focus of implementation. Over the past 15
years, the engagement of communities has at times been undervalued, as with early IMCI efforts that
assumed that increasing the availability of care in facilities would be enough or with polio eradication
efforts that relied on regular, massive campaigns rather than routine service utilization to sustain high
coverage. At other times, community demand factors have been acknowledged but not swiftly addressed,
as with perceptions early on that ORS did not cure diarrhea. For some, community engagement remains
one of the most important areas needing attention in order to accelerate improvements in child health.
There is a need to go beyond the health facility and move into the community. It is easier to establish scheduled
activities like immunization campaigns or routine immunization services compared with routine health services
needed to provide appropriate and quality care to sick children. (Multilateral, global)
One of the most significant challenges to child health has been the difficulty in scaling up what works.
There have been successes such as immunization and malaria prevention. However, achieving highly
effective coverage of other child health interventions requires the funding and political will for building
robust input systems (supplies, human resources), improvement in management (information,
supervision, quality), and demand creation.
There are proven interventions that would improve pneumonia case management at the facility level as well as at
the community level that are not being scaled up; so that is a missed opportunity there in terms of child health
programming. (NGO, global)
Country Ownership and Leadership
The presence of strong country leadership has contributed to improvement in child health outcomes, and
conversely the absence of committed leaders or weak leadership contributes to lack of progress. Weak
leadership in countries can be overcome by externally driven and funded activities, but they are much less
likely to be sustained over time as resources fluctuate or new external priorities arise. In the future,
country leadership will be even more critical as the locus for improving outcomes is expected to shift
decisively to country action.
In Africa, we have been complacent as a region. Political leadership didn’t realize what was at stake in the
MDGs. One great success is that 10 countries have achieved MDG 4 and another 15 countries reduced
mortality. We could have achieved better, but others didn’t internalize and focus on interventions seriously.
(Multilateral, region)
The Success of Child Health
The success of mortality decline over the past decade and, especially during the run-up for MDG 4,
clearly provided momentum to child health. Positive results built support but paradoxically have also
become a barrier to address the unfinished agenda. The data available for accountability may have helped
propel child health forward but they have not secured a continued commitment to reach those that haven’t
been reached.
16 Mapping Global Leadership in Child Health
Findings: Stakeholders, Initiatives, and
Coordination
Organizations
The organizations identified as active in global child health over the past 15 years are illustrated in the
word cloud in Figure 7. The size of the name reflects the frequency with which it was identified as an
important actor by study respondents. The most prominent organizations are UNICEF, USAID, WHO,
the Bill & Melinda Gates Foundation, the World Bank, GAVI, and the Global Fund. These were followed
by a second-tier group that includes PMNCH, Norwegian Agency for Development Cooperation (Norad),
the Department of Foreign Affairs, Trade and Development (DFATD), and the Reproductive, Maternal
Newborn and Child Health (RMNCH) Trust Fund. As a group, NGOs are also important, although no
single NGO stood out. The African Union was prominent in regional interviews.
Figure 7: Word cloud showing organizations identified in interviews as active in global child health
Despite their importance, the level and style of leadership that was exercised by these organizations
varied over time. UNICEF has the longest-standing mandate for child health, especially under the
leadership of James Grant in the 1980 and 1990s, who emerged as the most important champion during
interviews with stakeholders. UNICEF lost its eminence once new directors moved into broader child
rights and other fields, as global partnerships like GAVI and the Global Fund with specific purposes
grew. Similarly, WHO, with its important normative and technical mandate, was active, but the turnover
of leaders and internal reorganizations of child health sections worked against a strong presence. With
funding scarce and overwhelmingly earmarked to projects, child health has not stood out.
UNICEF has been a much weaker leader than it should have been over the last 15 years. There are of course
exceptions but it has not been the dramatic transformational leadership that we have seen before. (Foundation,
global)
Is it an important part of WHO’s role? I also think that the merging they’ve done of maternal as well as child in
the same place risks that all will be dominated by maternal and newborn. (Academic, global)
Earlier in the MDG era, USAID was an active leader, providing support and funding for child survival
through its country missions, NGOs, and centrally funded projects. As commitments to global
partnerships such as GAVI, the Global Fund, and polio eradication were made, as well as disease-specific
initiatives such as PEPFAR and the President’s Malaria Initiative (PMI), support for child health goals
was diminished and fragmented. More recently, maternal and newborn health have coalesced and appear
to have a stronger voice within USAID. However, in 2012, along with UNICEF and others, USAID tried
Mapping Global Leadership in Child Health 17
to refocus attention on child health with Ending Preventable Child and Maternal Deaths (EPCMD): A
Promise Renewed.
Obviously USAID has been a very strong voice for child survival. (Multilateral, global)
What’s disappointing about donors in general and USAID in particular is that they are not driving a discussion at
the global level about child health. (Bilateral, global)
The Bill & Melinda Gates Foundation has become a major force in global health through high levels of
funding and the use of its powerful voice. Child health–related needs and interventions are a high
priority—particularly polio eradication, immunization, malaria, nutrition, and newborn health—and
funding spans the spectrum from discovery to delivery. However, the organizational and strategy
structure of those areas relevant to children are spread out inside the foundation in disease, population,
service delivery, and country subgroups. This appears to be a barrier to more holistic work and makes it
difficult for outsiders to know how to collaborate.
What is the Gates Foundation trying to achieve? Talk about coherence and strategic focus. Seems hard to
understand what are its priorities. But certainly they are a very important voice and presence and source of
funding. (NGO, global)
The World Bank has played a major role in financing health and development in countries for decades.
However, they have risen to new prominence with their role in hosting the new GFF.
GAVI has made major contributions to saving children’s lives, albeit tightly focused on immunization.
As an alliance, it has deep buy-in from organizational members and working arrangements with other key
actors that leverage their comparative advantage (e.g., UNICEF’s country presence, WHO technical
resources, NGOs community orientation). Through a targeted health systems strengthening agenda, GAVI
is broadening the use of its platform in countries to support other child health interventions, but this
appears to be at the margins.
GAVI was an effective global intervention. It consolidated funds, raised a lot more money, set out a systematic
approach to countries, [developed] transition plans, and created incentives so that countries could adopt new
vaccines with reduced prices. (Multilateral, global)
The Global Fund is a large and influential financing organization that supports disease-specific programs
that also serve children in countries (malaria, HIV/AIDS, TB). More recently, it has implemented a new
funding model that provides support to health systems strengthening in addition to control of these
diseases. As part of the model, there have been specific efforts to incorporate iCCM into Global Fund
country plans.
The new funding model has really helped [stakeholders] think about systems strengthening, linkages across
programs. One of the new strategy objectives is really supporting integration of vertical programs in MCH.
(Multilateral, global)
PMNCH was originally established to bring together separate global partnerships and constituencies
under a model of the continuum of care. It was slow to develop and define its role in advocacy and
coordination, but it has been active in broadening the stakeholder field and gathering input into global
strategies and the SDGs. It will continue to convene stakeholders and will host the new accountability
mechanism for SDG monitoring. However, questions about the organization’s strategic position and
capacity remain. They are perceived as having a heavy focus on maternal and newborn health to the
exclusion of child health.
18 Mapping Global Leadership in Child Health
I think the whole establishment of the PMNCH [focused on] integrated care as an agenda. This was quite an
important achievement to bring the agenda together. (Bilateral, global)
I think PMNCH should have been a unifying platform but it’s not strong. It’s not helped for child survival as much
but it has for the continuum of RMNCH. (Foundation, global)
Initiatives and Groups
In addition to organizations, there have been a set of important initiatives or groups that have played roles
in moving child health forward. Initiatives vary by purpose, the breadth of their work, the level at which
they work, and the range of participants. Some of them have purposely time-limited mandates. Initiatives
are illustrated below. The size of the names reflect how frequently they were identified by study
respondents.
Figure 8: Word cloud showing initiatives/groups identified in interviews as active in global child
health
EWEC was launched to mobilize commitments and action across public and private sectors to end
preventable deaths of women, adolescents, and children. It elevated attention to maternal, newborn, and
child health (MNCH) to diplomatic levels, and its first strategy helped galvanize movement to achieve
MDGs 4 and 5. An independent review committee was commissioned to monitor progress. EWEC has
been an integral part of the SDG process and led the development of Global Strategy 2.0, which will
continue to coordinate and guide partners to reach RMNCAH objectives. While child health is addressed
in the strategy, it employs a continuum of care approach; thus it is unclear how much attention it will
receive. However, EWEC is the central umbrella for commitments to child health.
Working for that strategy in the beginning set off a strong EWEC and a sort of focusing on having that very
deliberately at the UN Secretary-General level. We were working on the advocacy aspect. And doing this in a very
political way but at the same time having technical work to accompany it. With all the partners involved.
(Bilateral, global)
The GFF is a key financing platform for EWEC’s global strategy launched last year. It is intended to help
bring additional resources and build financial sustainability for RMNCAH by enabling smart financing in
countries (more efficient investments in high-impact interventions), by leveraging more domestic
financing, and by ensuring harmonization and alignment with country-led plans and investment cases.
Mapping Global Leadership in Child Health 19
The first countries have just been approved, so while there is great optimism that this model will succeed
in supporting RMNCAH more effectively, there is also skepticism that it will succeed with investment
cases and bringing new resources. It is highly dependent on country leadership, donor willingness to
harmonize, and private sector engagement.
One aspect of it is to try to have an impact on the smarter use of resources or to aid in scaling up efforts. To
make sure countries that will graduate from aid in the coming years and will not fall back in terms of
achievements and results and child health is central to that. What efforts can be made at this stage to prevent
that from happening? The obvious is domestic resources and responsibility of governments. (Bilateral, global)
The GFF is not very relevant. I think the hype greatly exceeds its actual potential. (Multilateral, global)
Child Survival Call to Action, APR, and EPCMD
In 2012, the Child Survival Call to Action was convened by the US, Ethiopian, and Indian governments,
and several summits were held to rejuvenate a global child survival movement. This led to hundreds of
governments and organizations signing a pledge to stop women and children from dying of preventable
causes (APR). UNICEF has led the APR initiative with USAID and WHO as key partners. The APR has
had two goals: one was to achieve MDGs 4 and 5 by 2015; and the other, in keeping with SDG 3, is to
sustain progress until no mother, newborn, or child under five dies from preventable causes. Some people
questioned the need for the Call to Action targeting children at a time when framing of global RMNCH
health problems moved toward the continuum of care. However, APR helped countries consolidate child
health strategies, although it brought no new resources. In 2014, building on APR, USAID developed the
EPCMD initiative. This has included a global strategy, USAID missions’ plans for key countries, and
reporting frameworks.
With the Call to Action, I think we just needed at that point to reinforce that [child survival] agenda and reinforce
our interest in it. In some ways APR as a movement has had some impact on the country level; it’s refocused
attention on U5MR. (Bilateral, global)
APR didn’t bring enough partners; it was too much of UNICEF and USAID. Also not enough additional resources
were brought in. (Multilateral, region)
The Countdown to 2015 is a multidisciplinary collaboration that was intended to provide independent
evidence of progress toward MDGs and for accountability of countries and development partners. In
addition to developing methods for measurement, it provided critical, comparable evidence that visibly
demonstrated achievements (or lack thereof) to policy makers and technical leaders. For SDGs, a
Countdown-type mechanism is likely to be more decentralized with a regional locus and more country
capacity building, such that evidence will be more rapidly and effectively applied.
There was a lot of attention brought to country leaders on their performance around the MDGs. The country-
specific report cards and data sheets and helping to really pioneer use of that kind of regular routine updated
tracking at country level on a bunch of specific things. I don’t think at the global level itself accountability was
that effective. Some of the things Countdown pioneered such as the continuum of care, simple indicators, data
from a wide variety of sources—these have been more widely adopted. (Multilateral, global)
DPWG and the iCCM Task Force
By the beginning of 2000, technical working groups relevant to child health began to emerge. Often these
were for disease-specific interventions, but they also included groups focused on more cross-cutting
themes such as community health workers. Two groups that have been the most active are the DPWG and
20 Mapping Global Leadership in Child Health
the iCCM Task Force. Participants of both include UNICEF, WHO, USAID, other bilateral aid agencies,
foundations, and NGOs or NGO networks such as the CORE Group. The iCCM Task Force grew out of a
series of technical review meetings that were held as community case management (CCM) gained
momentum. Sharing of guidelines, experiences, tools, and studies across countries and researchers has
been valuable, and ultimately secretariat support was established with USAID funding through the
Maternal and Child Health Integrated Program (MCHIP)/MCSP. Led by a steering committee, it has
helped harmonize iCCM approaches and provided some visibility at the global level. Some subgroups
have been able to address specific bottlenecks or constraints to programs. The knowledge management
platform for the task force, CCMCentral.com, provides access to a wide range of iCCM program
materials and is an important forum for global stakeholder technical discussions. However, it does not
appear to promote priority attention to child health at higher political or diplomatic levels. Also, linkages
with countries are not well developed, limiting learning and effective dissemination.
The DPWG, established in 2011, provides technical assistance, resource mobilization, and evaluation
support to 10 countries to improve coverage of diarrhea and pneumonia treatment, and it convenes the
group for child health commodities under the UN Commission on Lifesaving Commodities (UNCoLSC).
Other technical groups that have supported or advocated for diarrhea and pneumonia work include the
Global Zinc Task Force (technical, policy, good manufacturing practice), the Mining Compact for Child
Health (sustainable markets for zinc, scale-up partnerships), and the PneumoADIP and HiB Initiative
(vaccines). The singling-out of pneumonia and diarrhea, whether through groups or meeting events, has
been important to retaining some level of attention.
The DPWG is reported to be an effective mechanism for information sharing among technical stakeholders, but there have been variable results in strengthening and scaling treatment programs in the focus countries. Despite the enthusiasm of participants, many report that this type of coordination
does not lead to real alignment of policies and interventions, as partners follow their own interests and
priorities and respond to their own funding streams. There is a sense that there is little impact on country-
level coordination, and fragmentation is visible at both global and country levels.
Sometimes there are so many partners, and this has been a concern especially in country where different
partners are asking for different things to be done in different ways with different priorities, Sometimes the
countries get overwhelmed. The countries have their country plans, but they end up implementing their partner
or funder plans. (Multilateral, region)
Leaders
Individuals were sometimes identified as leaders in the field of child health. Thirteen names were
mentioned but each by only a few people. The UN secretary-general was the most frequently identified,
mainly in relation to EWEC and its strategies. There is concern that with Secretary-General Ban Ki-
Moon’s replacement, RMNCAH will not be a priority. Most of the other people are associated with
organizations that work in development (multilaterals, bilaterals, academic institutions), and one held
elected political position. What is overwhelmingly clear is that child health has no obvious, public
champion and has not had one since James Grant. Further, it does not appear that champions are emerging
from the next generation.
There is the people factor – you can achieve so much if you have the right people….it’s a very thin field. How do
we build a new generation of child survival people? This is really important. (Foundation, global)
A Note on the Lancet
As noted earlier, the Lancet has played an important role in communicating information and bringing
high-level attention to child health, among other global health issues. The role seems to be one of creating
a space for experts to synthesize and comment on evidence, publicizing evidence more broadly in
Mapping Global Leadership in Child Health 21
development circles and with political leaders, using the editorial function to advocate for things that
advance the cause, and following up on reporting on progress and accountability. There is some worry
that this voice is being used too frequently on many issues, thereby lessening its influence.
For leadership, I find it interesting that the Lancet has jumped into a relative leadership vacuum to really give
some very provocative and compelling series on issues that are almost setting the global debate . . . which is an
odd leadership role to step into, but I think it’s been very important. (Foundation, global)
Coordination of Work in Child Health
The level of coordination of stakeholders and programs in child health has varied considerably over the
past 15 years. At the time of commitments made to the MDGs in 2000, there was a clear results focus and
common norms, but most key organizations pursued their own interests. In 2003, the Lancet series was a
turning point for commitment to child health that was followed by greater coordination, although usually
around diseases (e.g., malaria) or interventions (e.g., immunization, IMCI). In this same time period, big
global health partnerships or alliances were established and began to evolve, especially GAVI (1999) and
the Global Fund (2002). These partnerships brought member organizations together at the global level (in
boards and working groups) with requirements for coordinating mechanisms at the country level led by
governments (interagency coordinating committees and country coordinating mechanisms). Both GAVI
and the Global Fund have large, dedicated funding streams, explicit goals, and tight mandate boundaries.
GAVI, in particular, has established clear roles and expectations for global and country partners.
First there is a working group at GAVI and a board, and it forced the community to come to agreement including
the donors, the foundations, and UNICEF, to adopt common positions over time. When you get to that level
these require institutional buy-in past grand statements. (Multilateral, global)
Towards the end of the decade (2010), in an effort to accelerate progress toward MDGs 4 and 5, EWEC
brought more stakeholders together under a broader strategy umbrella that was centered at high
diplomatic levels (the UN secretary-general). EWEC gathered commitments from organizations,
employed accountability mechanisms to confirm progress, and held annual events that brought public,
private, and charitable sectors together. Coordination continued to be focused on diseases or interventions
within existing partnership organizations, technical working groups (e.g., DPWG, iCCM Task Force) and
global action plans (e.g., ENAP, GAPPD, Global Vaccination Action Plan). Coordination mechanisms
also expanded to include cross-cutting topics such as the supply of commodities for children (e.g.,
UNCoLSC/RMNCH Trust Fund), and data (e.g., Child Health Epidemiology Reference Group). In some
instances, organizations developed joint work plans or statements and donors funded organizations
purposely to enhance joint work and better coordination. Despite the drive for the MDG targets in 2015
and the launch of EWEC, which might have continued to unify stakeholders, a wide range of agency-
owned topic-specific initiatives emerged instead (e.g., APR, FP2020, ENAP).
We saw that targeted funding of institutions to work together was important. It gave them the possibility of
working together more closely. (Bilateral, global)
EWEC provides a large umbrella under which many different initiatives fall; but I think regardless there is still a
lot of disconnect and vertical initiatives. (Foundation, global)
As the MDGs came to closure, a more inclusive consultative process broadened the group of constituents
that developed the SDGs and EWEC’s Global Strategy 2.0. In part, this was intended to provide a better
basis for coordination. The GFF was established to strengthen financing, but also with the intent of using
country investment cases to drive closer alignment at country level. The PMNCH provides the venue for
seeking voices of many stakeholders. While the architecture is in place, uncertainty remains high. The
size and complexity of the partner environment has increased. Large numbers of branded and possibly
22 Mapping Global Leadership in Child Health
competing initiatives still exist and are causing fatigue. There is jockeying for visibility that is perceived
to occur between partner organizations, especially UNICEF and USAID.
At the global level in child health, there is a much more diverse set of people. Clearly there has been a
privatization of health influence. In the old days, it was WHO and UNICEF. Now it’s much more complicated
with a lot of actors. (Multilateral, global)
Since then I think a rather confusing period in global health governance has arisen. Different donors in the global
scene are trying to capture leadership for different parts of the agenda—EWEC with the UNSG and smaller
donors like Norad, APR with USAID, FP2020 with DFID, and GAVI keeping its own agenda. You actually have a
whole bunch of global voices saying pay attention to my problem—my agency is leading. What looks like
coherence isn’t. (Multilateral, global)
Today, child health is highly fragmented and siloed in the global arena, within stakeholder organizations,
and at the country level. Most coordination that has happened in child health has been within disease or
intervention boundaries. The best example of effective coordination at all levels is GAVI, which provides
access to vaccines, and country commitment and ownership of these programs is high. Coordination for
other intervention areas exists but tends to operate mainly for technical purposes and at the global level.
The network of experts and policy makers that came together around the Lancet 2003 series continued to
generate evidence and improve measurement, including through the Countdown, but didn’t influence
coordination around the child as a whole.
Within key organizations, child health is also siloed under disease areas or buried within broader MNCH
groups. Child health staffing has been limited compared with immunization or polio and more recently
maternal and newborn health. In part, this reflects funding availability.
Going forward, there was broad agreement that the most important aim for coordinating child health is to
do it well at the country level. Experience has shown that countries with strong leadership are able to
gather, align, and coordinate donor funding around their own national program, as evidenced in Rwanda
and Ethiopia. In countries with weak leadership, they are not well coordinated and development partners
have much higher visibility promoting their own interests. There are other challenges to making
coordination work such as variable donor funding cycles and multiple requirements for program
documentation that can have high transaction costs for governments. Global-level development partners
may ask that coordinating bodies be set up separately to consider specific topic areas. It is hoped that the
GFF investment cases will be an effective mechanism for improving coordination around a consolidated
country plan, but this is expected to take support, time, trust, and compromise.
The countries can be asked to set up three or four different coordinating mechanisms all around one aspect of
child health. So it is quite frustrating at the country level to deal with this as well as very time consuming.
(Multilateral, global)
It’s another organization to work with for development aid (GFF) and we are working toward strengthening the
issues around coordination. Working to support national plans so that we don’t continue to fragment and support
only particular issues in MCH. (Bilateral, global)
Certain practices appear to support better coordination. Having comparable data for all countries
available, tied to accountability, helped bring countries and the global-level community into dialogue. The
development of joint strategies and work plans among organizations and governments generated common
commitments that worked, especially when there was targeted funding that allowed organizations to play
complementary roles. Consultation early on in the process of developing goals, strategies, or roadmaps
Mapping Global Leadership in Child Health 23
tended to build buy-in. Relying on more than one venue or mechanism (although not too many) offered
alternative linkages and reinforcement.
I think we have tried as hard as we can to see things together and to open spaces where we can work together.
It is still challenging. (Bilateral, global)
It is not clear how organizational behavior that constrains coordination in child health will be addressed or
who will do it, as there is little leadership at the global level to bring the community together.
Findings: Political Commitment and
Funding
Political Commitment
The World Summit for Children and the MDGs (MDG 4, specifically), established the formal space for
commitment to child health. While countries publicly agreed to work toward the MDGs, political
commitment for child health did not begin to strengthen until in 2003, when the technical network
coalesced. Afterward, political commitment was still variable but grew, associated with accountability
efforts. The technical network or parts of it went on to work with countries on Countdown case studies,
measurement systems, intervention packages (e.g., iCCM), and documenting evidence for newborn
health. These had variable effects on political commitment within countries.
The financial crisis of 2008 and the increasing importance of global partnerships (GAVI, Global Fund,
RBM) and their funding needs may have contributed to a gap or slowing of commitment for traditional
child health interventions. This was not addressed until 2010, when prospects for MDG 4 looked poor and
EWEC and its first strategy were set up as an umbrella for MNCH. EWEC highlighted diplomatic
engagement and broadened the community of those committed, but it was only loosely coupled with the
child health priority activities of the traditional stakeholders. Several other initiatives or groups were
established to accelerate or strengthen child health progress and linked to the EWEC framework. The
most successful of these included the RMNCH Trust Fund (UNCoLSC).
Child health has not had the political will or resources at the global or country level. (Bilateral, global)
The global health initiative environment was crowded as the MDG era came to a close and remained
dominated by vertical intervention actors and programs. Political commitment was reportedly higher for
immunization and malaria and increased for maternal and newborn health. As the broader SDGs were
developed, the target indicators for SDG 3 are intended to focus attention on child mortality as well as
maternal mortality and family planning. Even though the child health technical network advocates for
attention to ending all preventable deaths of children under five years, the newborn health network is far
more visible. WHO, UNICEF, and USAID promote broader child mortality goals and high-impact
interventions within their own new strategies (aligned with EWEC). However, it is not yet clear whether this
will be accompanied by increased political commitment to child health, and it may remain uncertain for
some time.
Within the SDGs there continues to be a strong political commitment; it [child health] is an important part of the
SDGs and there is the vision of ending preventable maternal and newborn death in the next 15 years. (NGO,
global)
I think the child health community does have the challenge of making sure that the top prioritization of child
health does not get watered down in a very large development agenda. (Foundation, global)
24 Mapping Global Leadership in Child Health
The GFF targets RMNCAH financing and, under the World Bank’s overarching work, there may be an
opportunity to enhance political commitment to child health and address the unfinished agenda in
countries (through investment cases) and globally.
Situate the RMNCH agenda within the universal health care agenda and make the case that the way or the
path to universal health coverage must be through getting essential services (not just health care but
multisectoral) for RMNCH. (Multilateral, global)
In order to strengthen political commitment to child health in the future, how it is described and promoted
matters. Some believe that the community should build on what has succeeded in the past: reporting
results in mortality terms. Others suggest that this is not enough and being able to persuasively report
investment impact or return on investment will be increasingly important in the SDG environment.
It is important to continue to talk about what we do and have done that has worked because there are still a lot
of people who think child survival money is bad after good. We have to find a way to communicate more
effectively around impact on those countries and people who have not been reached. (NGO, global)
Conclusions: Advancing Child Health
The Future Environment
Effective strategizing for the advancement of child health over the next several years is at a critical
juncture. There are several features of the evolving global context that are important to consider that
emerged from interviews and documents:
The level of uncertainty for development support is high in the near term, due to the major shift in
global goals and strategies, the refugee crisis in Europe, other humanitarian crises including fragile
states, and impending changes in leadership of institutions key for child health, especially the United
Nations, WHO, and the US government.
The implications of the shift to the SDGs for health or children are still emerging, but priorities,
political commitment, and likely funding will be more broadly distributed and possibly with less
clarity of purpose. If any of these resources are “zero-sum,” child health (other than immunization) is
likely to be working with less.
The four indicator targets for SDG 3 have been designed to capture and ensure the prominence of
maternal, newborn, and child mortality and family planning within the goal of health and well-being.
There is a risk that relying on U5MR alone will not ensure continued attention to the unfinished
agenda for postneonatal child health. Disaggregation of postneonatal mortality rates in relation to
burden is likely to be helpful.
The Global Strategy 2.0 for RMNCAH signals a change from earlier strategies, in its broader and
integrated approach and its increased emphasis on scaling up, equity, and country locus. It is not clear
how well “survive, thrive, transform” will drive focus on outcomes as the MDGs did. This, and the
continuation of earmarked funding, may lead to more, not less, fragmentation as agency priorities are
carved out.
The World Bank has heightened its presence in RMNCAH with the GFF. There is political reliance
on the GFF to finance and rationalize financing of child health, especially those components not
financed through GAVI or the Global Fund. However, there is a high level of uncertainty reported
about its potential and actual effectiveness or how long it will take to have an impact in countries.
The high-level core architecture for child health (and RMNCAH more broadly) is emerging as in
Figure 9. It will be very important to track the place and priority of child health within this
Mapping Global Leadership in Child Health 25
architecture. Without proactive monitoring and follow-up action, the child health community may
lose positioning or miss opportunities for advancement.
26 Mapping Global Leadership in Child Health
Figure 9: Organizational and initiative architecture for leadership in global child health
Effectiveness of Child Health Networks
Improved child health remains an important aspiration at the global level; but it does not currently hold a
position of prominence nor can it count on sufficient commitment to meaningfully advance or transform
the agenda to reach the vision for 2030. This time period is a turning point and provides a good
opportunity for child health advocates to make changes that enhance progress.
Child Health Issue Characteristics
Child health has been a central pillar of global health for many years and is still an important part of the
vision for the future. Children as a group are valued and this should continue to resonate publicly, but this
strength has not been tended to adequately. The child health community’s attention has been focused
elsewhere, and it appears that they may have lost connection with the most basic underpinning of the
child survival revolution’s political power.
The reduction of child mortality during the MDG era has been widely recognized as a stunning success,
but this has come at the cost of the perception that the job has been finished. The truth is that there are
still many preventable deaths of children and that inequalities are pervasive, but this is not broadly
recognized outside the child health community. Under-five child mortality in sub-Saharan Africa is much
higher than in the rest of the world, and 60% of it still occurs in the postneonatal period, for which there
are well-proven, effective solutions that are not getting to people. A striking preponderance of these
deaths are readily preventable with low-cost interventions.
Globally, it is believed that immunization and malaria programs have had more impact than pneumonia
and diarrhea interventions. In the first decade of the 2000s, the child health community placed a big bet
on IMCI as the best approach for sick children, but it floundered. While IMCI was conceptually sound,
problems emerged with the complexity and scale of implementation needed. These problems and the push
EveryWomanEveryChild
(GlobalRMNCAHStrategy2.0)
(SpecialAdvisor)
PMNCH Global
Financing Facility
Host: UNSG
Host: World Bank Host: WHO
Technical Support Agencies
• UNICEF • USAID
• WHO
• UNFPA
• + other H8
POLICY COMMITMENTS
INVESTMENT CASES
FINANCING
CONSULTATION WITH CONSTITUENCIES
ACCOUNTABILITY
‘New’ Countdown
for Tracking &
Accountability
• Technical Guidance • 3 Regional Hubs
• Country capacity
building
M&E Reference Group
• Indicators
• Methodology
• Data quality
Host: WHO
Mapping Global Leadership in Child Health 27
for IMCI persisted, consuming resources, but most importantly without the self-correcting mechanisms
that might have redirected efforts into more effective adaptations or approaches earlier. With the
exception of the development of preventive vaccines, pneumonia and diarrhea programs suffered the
most.
Child Health Network and Actor Features
Leadership is essential for maintaining and rebuilding the momentum of child health. People interviewed
for this study uniformly reported, that for the past 20 years (since James Grant at UNICEF), no effective,
individual global champion for child health has emerged. Further, it is not clear that new effective
champions are developing from the next generation of child health proponents. Similarly, in the past 15
years, there has been weak or disinterested leadership exhibited by global organizations with mandates for
child health. These gaps were felt the most strongly for UNICEF, WHO, and PMNCH, whose leaders
appeared to focus on other priorities in the post-2000 decade.
With what appears to be a more mindful and decisive shift of locus of health development action to
countries, country leadership—which has always been important—is now critical. High-level political
decision makers in countries, who may or may not be technical also, are central to achieving gains in
child health. The future is not about others doing more in countries, but countries directing and doing
more themselves with the resources that can be brought to bear.
At certain time periods during the last 15 years, there was momentum for child health in pursuit of MDG
4. Starting with a child survival network (the first Bellagio Group) and continuing with the Countdown
and EWEC, child health was raised up, contributing to successful mortality decline. However, this
momentum has not transitioned through to the SDGs. Perhaps no health issue has yet transitioned, but the
child health community urgently needs to find effective ways of mobilizing support that builds on the
SDG concept and focuses attention on children for the next 5–10 years. APR (and EPCMD for USAID
internally) has helped consolidate strategy for some, but its potential role and future seems limited.
Child health has become increasingly fragmented and siloed as a field and within organizations. It has
been divided into diseases, population subgroups, and intervention packages that rarely come together and
are sometimes juxtaposed. This contributes to competition and is reinforced, sometimes unintentionally,
by the decisions and actions of donors and development partners in supporting subgroups. Similarly, child
health has become less visible within key organizations. It has been lost within PMNCH, and periodically
within UNICEF and WHO, and is structurally divided in the Bill & Melinda Gates Foundation and
USAID. It is increasingly separated from maternal and newborn health, especially with the prevailing
focus on childbirth and the time around delivery. Few spaces appear to exist in which MNCH is brought
together. In part, this fragmentation explains the lack of a unified and compelling child health vision.
Since the 1980s, there have been affinity or working groups that have brought together experts and
practitioners around specific technical topics for child health. These have been convened by multiple
organizations and have served to pool information, build consensus on evidence, guidelines, and
measurement, publish information, and sometimes coordinate action. More recent examples include the
DPWG and the iCCM Task Force. These groups have shown mixed effectiveness and have generally not
served to leverage action across disciplines or raise the profile of child health. But these groups are
focused on narrow goals, and it is important that expectations of influence be matched to these goals.
In the post-2015 environment, child health needs to be reframed to speak to new strategies, actors, and
opportunities. The environment will be shaped by new organizational strategies (e.g., UNICEF, USAID,
WHO), the Global Strategy RMNCAH 2.0, the SDG 3 statement, and its four absolute targets: 12%
(reduction in neonatal mortality rate); 25% (reduction in U5MR); 70% (reduction in maternal mortality
rate); 75% (increased access to family planning). All of these strategies continue to highlight ending
preventable child deaths and some seek to promote child well-being more broadly in the context of UHC.
28 Mapping Global Leadership in Child Health
There is consensus on how child health should not be reframed. Given changes in child health such as the
structure of causes of death and individual risk or needing to reach the hard to reach, quick fixes and
magic bullets will not work. Similarly, very vertical or piecemeal approaches or interventions will be
inefficient and insufficient to sustain health services and benefits at scale, implying integration.
Future child health framing should start with a holistic approach to all aspects of child health (newborns,
infants, and children together) and contain a more explicit expression of equity, because without it
mortality will not reach targets. Health systems and platforms need to be addressed, focusing on
commodities, health workers, and quality, including all levels from community through hospital and the
linkages between them. Flexibility will be a necessary capability of health systems so that delivery can be
rapidly adapted to local contexts to respond to need. And with more forward scanning, systems can be
adjusted or redesigned in a more mindful and responsive way.
The greatest challenge with reframing is one of communications and resonance with audiences that wield
or will wield influence and power. Ending preventable deaths, on which the community now relies, is not
sufficient because it appears, based on feedback collected for this study, to lack compelling resonance.
Child Health Policy Environment
There were consonant expectations of what should be addressed in child health driven by a common,
measurable goal (MDG 4), unified by the Bellagio Child Survival Group, and pinpointed in the Lancet in
2003. This was later reinforced by EWEC and APR, although there were variable expectations and
fragmented support for how to deliver proven interventions that met child health needs. Now, post-
MDGs, it is not clear that there is a holistic view of strategies to address priorities and provide support for
child health programs despite compelling synthesis and publication on current disease burden and the
unfinished agenda.
Child health stakeholder and organizational interests have been aligned around various and diverse
components of child health. In particular, GAVI and its work with childhood immunization was identified
as the most highly aligned and therefore most successful in recent history. While GAVI and its process
adds high value to child health outcomes, it doesn’t lend power to other child health components (e.g.,
treatment) nor to the whole child more generally.
As noted earlier, organizations have also tried to align interests around technical themes such as
pneumonia or iCCM or around subgroups such as newborns. In the case of technical working groups,
there is sharing but not enough work at leveraging influence for added value. Some pointed to actions
demonstrating that rather than group action, individual organization agendas were forwarded.
Perhaps most concerning for the future is that after 2010, a surfeit of big and small initiatives in child
health began to appear. These were usually branded by agencies and credit was claimed by those
agencies. This sometimes led to partners jockeying for positioning as successful leaders or doers, with the
jockeying visible and counterproductive to the larger effort. Looking underneath some of this behavior,
there are core norms and values for child health on which there is agreement and mutual respect was
reported. Understanding how to build on this core for more cohesive action would likely be more
effective.
In the early part of the decade after 2000, well-funded global partnerships like GAVI and polio
eradication competed for child health resources, and there is some worry that they may capture a
disproportionate portion of resources in the next five years. Development assistance for health has
increased since 2000 for newborn and child health, although it has not increased as sharply as for
immunization and polio. Since 2009, newborn and child health funding has grown faster than other health
programs such as HIV, malaria, or TB but from a relatively lower base. There are also strong sources for
these funds in government (UK, US) and large foundations (Gates). This demonstrates that important
Mapping Global Leadership in Child Health 29
financial commitment exists for child health even though the future is less certain. Combined with the
potential for the GFF to influence spending in countries, there may be a window of opportunity to
improve child health support, but it will behoove the child health community to track what happens
closely and respond quickly.
As the world and global health look forward to 2030, this is a time of high uncertainty for child health.
Such times may be viewed both as a threat and as an opportunity to momentum. Either way, what will be
required is a community more highly attuned to windows of possibility, the will to take advantage of
them, and the structure to collaborate.
Recommendations
What should the global child health community do to make sure that the full range of child health issues
are at the forefront of the global health landscape?
Reframing Child Health and Communicating It
How should child health be framed, both strategically and substantively, to reflect the realities of 2016?
Recommendation 1: With the shift to the SDGs, child health should be deliberately reframed so that it
emphasizes the value of children, a more holistic approach including “newborns and infants and children”
as one, and a clear aim for equity.
In addition to the reframing, it is equally important that resources be applied to crafting how the framing
is communicated more effectively than the current messaging. Communications probably need to evoke
the value of children as a driver for ending preventable death.
Re-establishing Leadership
Who has the stature to lead, and what does the global child health community need to do (and avoid) to
inculcate and support this leadership?
Recommendation 2:
a) The principal global partners in child health need to come to agreement on and then designate and
support a lead organization to consistently provide overall messaging for child health.
b) They also need to seek and nurture over time one or several credible champions who will speak
powerfully for child health on the global stage.
The organization could be drawn from any of the major ones highlighted earlier, but it needs to have
legitimacy, be positioned in the emerging architecture, and be able to be heard by all actors. Once
designated, it needs to be decisive in its prioritization of child health, and other organizations need to be
clear in their public support. Similarly, child health must have new champions at high levels. Without
this, commitment to child health will continue to falter.
Reversing Fragmentation and Coordinating Effectively
How should child health stakeholders (organizations and initiatives) align and advance collaboratively
toward goals?
Recommendation 3: Key stakeholders need to create and implement a shared strategic approach for:
a) Raising the visibility of child health as a whole rather than in subcomponents
b) Ensuring a strong child health voice in Strategy 2.0, SDG 3 monitoring, and the GFF
30 Mapping Global Leadership in Child Health
c) Bridging child health components of existing strategies across institutions in such a way that country
action is more likely
In addition, investments should support collaboration and explicitly dis-incentivize fragmentation within
child health.
There are multiple strategies that incorporate child health that were recently launched globally (EWEC
2.0, UNICEF, WHO, EPCMD, etc.). All of these strategies embrace a continuum of care, some more
broadly than others, so the challenge is to promote the common core for child health with a recognizable
and compelling voice. It is not yet clear what such a strategic approach should look like or what
actionable milestones are really needed (analogous to what the ENAP is for newborn health), but it starts
with child health advocates coming together to create a way forward. That way forward should build on
what has been learned from the Call to Action, APR, and similar efforts in maternal and newborn health.
New child health framing might also suggest new or re-emerging alternatives.
To help ensure that investments do not reinforce fragmentation in child health, there are design and
learning steps that should be taken right away. This could be as simple as assessing unintended
consequences of a project or a meeting or establishing broader linkages at the outset. Current investments
must be assessed through the lens of their contribution or status as barriers to whole child health.
While there are identifiable child health proponents, there does not appear to be a clear network or core
group that has taken on the mandate to propel child health forward together. However, the charge to such
a group is to carry this recommendation forward.
The stakeholder environment for global health is more crowded and complex than it was five years ago
and there are many coordination mechanisms at multiple levels. Going forward, the most important place
to get coordination right is at the country level.
Recommendation 4: Focus on a few key coordinating mechanisms for child health and support their
performance appropriate to objectives, roles, and participants. Close those that do not provide enough
value at both global and country levels.
There are multiple coordinating mechanisms and venues for child health at all levels. Some are given—
the PMNCH, GAVI, Global Fund, EWEC, and so on. For these, the child health community should assess
potential benefits and costs, then work with them accordingly. Similarly, technical or thematic affinity
groups may be useful for learning but should focus on a clear or limited purpose with right-sized support.
At this point in time, there may not be an existing venue or mechanism that would allow development of
a strategic approach by child health leaders and advocates. Then the question becomes whether one can
be repurposed, or one formalized from something less formal, or whether it is necessary to create a new
space—either formal or informal—for the core network.
During the study, the problem of required but ineffective coordinating mechanisms at the country level
was raised multiple times. Countries will differ in terms of what works, but rather than continue a façade
with a mechanism, stakeholders should endeavor to make it permissible to abandon those that don’t work
and try something different, preferably building on existing platforms.
Data and Accountability
How will the child health community know there is progress and hold stakeholders accountable?
The Countdown reporting and accountability process worked reasonably well to build commitment to
child health during the MDGs. There are three linkages in the SDG architecture that the child health
community will need to make to continue to leverage this function. The first is the Independent
Accountability Panel within the PMNCH that replaces the Commission on Information and
Mapping Global Leadership in Child Health 31
Accountability. The second will be the next version of a Countdown-type mechanism that is under
development now. The third is the Monitoring & Evaluation Reference Group hosted by WHO, which is
likely to focus on measurement of maternal and newborn health in the near term.
Recommendation 5: Ensure that child health data and information are well represented, packaged, and
reported within the context of the emerging evaluation groups.
Country-Level Focus
By far, the strongest finding that emerged from this study was acknowledgment of the shift of locus for
transformation and sustained action from the global to the country level. While there have been many
statements over the years and more effort recently to ensure country partnership, country leadership, and
country investment, there appears to be more commitment to making it happen. The success of the GFF
depends on it. The country should be part of the reframing of child health.
Recommendation 6: Reframe child health with the country at the center and purposely engage differently
with countries with weaker systems and leadership to sustainably improve child health. Invest in tracking
and learning from the process.
It is apparent that countries with strong leadership will themselves direct how child health will improve
and how global or regional partners will engage with them to do it. For example, Ethiopia used its
existing costed plan for the GFF investment case. This does not appear to be a matter of contention, and
donors appear to be increasingly willing to support strong country leadership. The challenge is how best
to address countries with weak leadership, which continue to be numerous. Development partners will
need to explicitly and in coordination with each other determine whether the challenge of helping to
encourage the development of stronger country ownership and national health systems warrants the risk
of slower progress in achieving health targets. This is a fundamental policy decision that must be reached
with a clear understanding of specific country realities and should not be applied as a blanket policy
across all countries. The reality is that some countries will respond to this stimulus by moving to meet the
challenge, albeit slowly, while others may use flexibilities to act on agendas far removed from the SDG
child health goals. Investing in tracking and learning about how and why this happens will be critical.
This process is likely to be the single largest challenge facing the global child health support community
over the next 15 years.
32 Mapping Global Leadership in Child Health
Appendix A: Methodology Details
Detailed Methodology: Qualitative Case Study of Global Leadership
in Child Health
Study Questions, Definitions, and Boundaries
(1) What are the current global leadership groups, initiatives, and fora focusing on all elements of
child health? (Please think of technical areas including infections, nutrition, prevention, and
protection. Please think of systems areas including financing, quality, metrics, and
accountability.) Who currently leads the leadership groups, initiatives, and fora? How are these
currently led and coordinated?
Groups: global partnerships, multilaterals, bilaterals, foundations, nongovernmental organizations
(NGOs), for-profit and nonprofit private sectors, and individuals
Fora: meetings and events
Initiatives: formal endeavors intended to improve child health
(2) What were the major lessons learned about past and present global health leadership efforts?
(not related to child health; summarized from the literature)
What worked in what context and in what time frame? (Successes)
What did not work in what context and in what time frame? (Challenges)
Why?
General global health governance
Maternal health
Newborn health
Immunization (GAVI)
HIV, TB, and malaria (Global Fund)
Nutrition (Scaling Up Nutrition)
(3) What strategies were employed to move the child health agenda forward? What factors shaped
the movement of this agenda? How did the strategies and factors interact over time to move the
agenda forward?
[Will cover:
What has been learned from previous efforts to coordinate or provide global child health
leadership?
What aspects or dynamics of child health make global leadership challenging?]
In order to trace child health strategies, actions, and results in depth, and in the time available to do
this exercise, we will use four tracer topics. The history of these topics is not mutually exclusive; we
expect to see interactions both within and between these topics.
Child mortality in Millennial Development Goal era and the Sustainable Development Goal era
Integrated Management of Childhood Illness and integrated community case management
(iCCM)
LA
ND
SC
AP
E
CH
RO
NO
LO
GY O
F A
CT
ION
& C
HA
NG
E
Mapping Global Leadership in Child Health 33
New vaccine introduction in an immunization program (pneumococcal vaccine)
Diarrhea and pneumonia
Strategies: Policies, plans of action, and actions and their results
Factors: Shiffman and Smith’s framework
Describe the overall financial resources required for each step in the timeline present in the data
summaries
(4) How can we structure global child health leadership to best support improvement in child
health outcomes? How could or should global child health fora relate to, engage with, or work
with regional institutions and countries?
Data Collection Methods and Organization
(1) Conduct a desk review.
Published and gray literature search
Organization and agency websites
Identify financial references through consultation with an expert (Maternal and Child Survival Program)
Set up stakeholder, strengths, weaknesses, opportunities, and threats (SWOT) table (for leaders,
groups, current initiatives).
Stakeholder group Strengths Weaknesses Opportunities Threats
Strengths: In what areas do the leader, group, and initiative excel?
Weaknesses: What liabilities do the leader, group, and initiative have? What activities do the
leader, group, and initiative perform poorly?
WH
O,
HO
W T
O W
OR
K
34 Mapping Global Leadership in Child Health
Opportunities: What favorable circumstances or situations do the leader, group, and initiative
present?
Threats: What potential challenges do the leader, group, and initiative present?
Set up chronologies from documents.
Example
iCCM
1980s 1990s 2000–2005 2006–2010 2011–2015 2015 to
present
Structure
Actors
Policies and
guidelines
Activities and
key events
Challenges
Solutions
Results
Summarize lessons learned using examples unrelated to child health.
Summary with narrative and a table
Provide financial data.
http://www.healthdata.org/sites/default/files/files/policy_report/2015/FGH2014/IHME_PolicyReport
_FGH_2014_0.pdf
High-level summary with a table and graphs
(2) Conduct individual, in-depth interviews (approximately 30).
Select respondents that include a mix of child health experts or decision makers.
Type of organization Area of expertise Background perspective
Multilateral
Bilateral
Foundation
Academic institution
NGO or technical assistance agency
Private
Government
Maternal, newborn, and child health
Nutrition
Infectious disease
Systems (quality, supply, metrics)
Social and behavioral change
communication and community
Financing
Policy advocacy
Health care provider
Public health professional
Economist
Systems
See file: CH Mapping Interviews Questionnaire version 1 (Appendix B)
Transcribe and code interviews using the Dedoose software.
First level to child health strategy themes to place information into chronologies
Second level to Shiffman Framework
Orient SWOT forward toward strong leadership for improved outcomes.
Strengths: How can a stakeholder’s strength help achieve objectives?
Weaknesses: Will the stakeholder’s weaknesses hurt or help in achieving the objectives?
Opportunities: Will an alliance with this stakeholder help achieve objectives?
Threats: How can the stakeholder’s threats be minimized?
Mapping Global Leadership in Child Health 35
(3) Data consultation (individual and possibly groups)
Confirm chronologies, including Shiffman factors and forward-looking SWOT, with key informants
as feasible.
Review initial findings with the Advisory Committee (January 2016).
Interview List Table 3: Number of interviewees based on type of organization
Type of organization Number interviewed (N=33)
Multilateral and global partnership 10
Bilateral organization 6
Foundation 4
Academic institution 1
NGOs 6
Private sector 1
Other interviewees from sub-Saharan Africa region 5
36 Mapping Global Leadership in Child Health
Appendix B: Instrument
Maternal and Child Survival Program Global Child Health Mapping
In-depth Interview Guide
Date:
Name, title, and affiliation of respondent:
Main areas of expertise:
Interviewer:
Introduction
Thank you very much for setting aside time to talk with me today.
The Maternal and Child Survival Program (MCSP), funded by the United States Agency for International
Development (USAID), is mapping global leadership and coordination of child health to better
understand how the global leadership for child health has evolved and identify opportunities for
enhancing outcomes now that the effort to achieve the Millennial Development Goals has ended. You are
being interviewed because you and your organization are important stakeholders in the child health
community.
This is a confidential interview. All identifying information will be removed, and any information or
examples we discuss, and quotes that might be used in the study report, will not be attributed to a specific
person or institution. You are free to not respond to any of our questions or to stop the interview at any
time.
The interview will take about an hour.
[If needed: To make sure I capture all of your feedback, is it all right with you if I record this interview?]
Before I begin, do you have any questions?
Questions
We would like to understand your perspective on the major strategies and events that helped or
constrained achieving improved child health globally. For the purposes of this study, we would like to
focus on the past 15 years (since about 2000) and on the health of children under 5 years of age.
1. In the past 15 years, how have you engaged in child health? (Probe: Do you have any areas of
specialization? Clarify regional role, if any.)
a. For which organizations have you worked during this time?
Note to interviewer: For Question 2, if the respondent has a role in an African region, ask for both the
global level and for the sub-Saharan Africa (SSA) region.)
Mapping Global Leadership in Child Health 37
2. What do you think were the most important global successes for child health? (For respondents
from Africa: What were the regional successes in Africa?)
a. What were the biggest disappointments? (Probe: What were missed opportunities, if any?)
Events and Strategies
Instruction to the interviewer: Ask the general question, then follow up for more specific examples, if any,
in one area relevant to the respondent’s background (e.g., Millennial Development Goals (MDGs) and
Sustainable Development Goals (SDGs), Integrated Management of Childhood Illness (IMCI) and
integrated community case management (iCCM), immunization, or pneumonia and diarrhea). Ensure that
present day is included.
3. Reflecting over the time period from 2000 to now, what were the major strategies and events
that advanced the child health agenda and helped achieve results? […that advanced iCCM,
pneumonia and diarrhea, etc.]
4. What were the major barriers or bottlenecks that critically challenged progress? (Probe for
African region interviews: What were they in the African region?)
5. Who were the important leaders (people or organizations) advancing the child health agenda?
(Probe: iCCM Task Force, Diarrhea and Pneumonia Working Group) (Probe for African region
interviews: Who were they in the African region?)
a. What did [the leader] do that was important?
b. How did the key stakeholders for child health work together? How effective was this
coordination?
Factors
Instructions to interviewer for Question 6: Use the key strategies or events reported by the respondent in
the previous question (e.g., for strategy ‘x’…).
6. How did the [strategy or event] affect the political commitment for advancing child health?
(Probe for what affected priorities, policies and programs, and resources.)
7. How would you describe global political commitment to child health now and in the context of
SDGs? (Probe: How is it prioritized relative to other global health issues?) (Probe for African
region interviews: How would you describe this in the African region?)
a. Why is it at this level?
b. What needs to be done to raise political commitment to child health?
Stakeholders
8. Who are the current influential stakeholders in child health at the global level? How are they
influential? (Probes: What are they doing to support child health? Have they raised any concerns?
(Probe for African region interviews: Who are the current influential stakeholders in the African
region?)
a. How does child health fit into your organization’s priorities?
38 Mapping Global Leadership in Child Health
9. What is the nature of the current working relationship between [stakeholder] and other key
stakeholders?
The Future
10. What is your vision of success for child health 5–10 years from now?
11. What are the three most important things that should be done to more rapidly achieve that
vision?
12. How would you strengthen the collaboration among organizations, groups, and partnerships to
get these things done? (Probe about collaboration between global and regional levels.) (Probe for
African region interviews: How would you strengthen the collaboration between global and regional
and regional and country levels?)
13. Is there anything else you would like to add? Is there anything you would like to ask us?
Thank you for your time.
39 Mapping Global Leadership in Child Health
Appendix C: Desk Review of Lessons Learned
Global Health Partnerships Summaries
No Author and
date Title
Global health
partnerships (GHPs)
assessed
Contributions Challenges and lessons learned Next steps and
recommendations
1 Buse and
Harmer
(2006)
Seven habits of highly
effective global public-
private health partnerships: Practice and
potential
• African
Comprehensive
HIV/AIDS Partnership • Alliance for
Microbicide
Development
• Aeras, Global TB
Vaccine Foundation
• European Malaria
Vaccine Initiative
• Foundation for
Innovative New
Diagnostics
• Global Alliance for the
Elimination of Lymphatic
Filariasis
• Global Alliance for
Improved Nutrition
• Global Alliance for TB
Drug Development
• Global Alliance for
Vaccines and
Immunizations
• Global Fund to fight
AIDS, TB, and Malaria
• Global Health Council
• International AIDS
Vaccine Initiative
• Institute for One
World Health
• International
Partnership for
Microbicides
• International
Trachoma Initiative
• Mectizan Donation
Program
• Microbicides
• Getting specific health
issues onto national and
international agendas • Mobilizing additional funds
for these issues
• Stimulating research and
development (R&D)
• Improving access to cost-
effective health care
interventions among
populations with limited
ability to pay
• Strengthening national
health policy processes and
content
• Augmenting health service
delivery capacity
• Establishing international
norms and standards
• Global health partnership (GHP)
alignment is ‘out of sync:’ GHPs are
inherently issue-specific and quick-results oriented, making it difficult for
them to follow and align their
assistance with the national priorities
of recipient countries.
• GHPs are not representative of their
stakeholders: Many GHPs fail to give
legitimate stakeholders a voice in
decision-making on the respective
governing bodies
• Poor governance: Many GHP fail to
clearly specify partners’ roles and
responsibilities. Furthermore, there is
often inadequate performance
monitoring, oversight of corporate
partner selection (conflict of interest),
and lack of transparency in decision-
making.
• Vilification of the public sector:
There has been a diminished sense of
the ‘public’ nature of global public
health initiatives.
• Inadequate finance: There is a
tendency for GHPs to lack the
necessary resources to carry out
planned activities or to fund the true
costs of activities.
• Poor harmonization: GHPs have
failed to harmonize their procedures
and practices with one another and
with other donors. This leads to
duplication in planning, monitoring and
evaluation (M&E), finance management,
and parallel systems for service
delivery.
• Inadequate incentives to partner-
• GHPs need to embrace aid
modalities (national ownership, etc.)
to integrate efforts with the national planning process and minimize
transaction costs.
• Strive for a more balanced
representation of stakeholders in
governing bodies.
• Need to reassess the idea that
market-based approaches are more
efficient than public sector
approaches.
• GHPs need to improve their
oversight.
• Partnerships need to be adequately
resourced.
• Partner organizations need to
address the particular demands that
partnerships place on participants.
40 Mapping Global Leadership in Child Health
No Author and
date Title
Global health
partnerships (GHPs)
assessed
Contributions Challenges and lessons learned Next steps and
recommendations
Development Program
• Micronutrient Initiative
• Medicines for Malaria
Venture
• Pediatric Dengue
Vaccine Initiative
• Roll Back Malaria
(RBM)
• Stop TB
• Vaccine Fund
facing staff: The organizational
commitment and loyalty employers’
demand of their staff—often explicitly
forbidding staff to have outside
interests, particularly if there may be
apparent, potential or real conflicts of
interests.
2 Buse and
Tanka
(2011)
Global public-private
health partnerships—
lessons learned from 10
years of experience in
evaluation
• RBM 2004–2008
• Global Fund to Fight
AIDS, TB, and Malaria
(GFATM) 2002–2007
• International AIDS
Vaccine Initiative (IAVI),
2003–2007
• Global Alliance
Vaccine Initiative (GAVI
Alliance), 2000–2005
• International Partnership for
Microbicides (IPM)
• The Stop TB
Partnership (Stop TB),
2001–2006
• Medicines for Malaria
Venture (MMV)
• Global Alliance for the
Elimination of Leprosy
• Creating novel institutional
spaces for more inclusive
global health governance
through innovative shared
decision-making, risk sharing,
and knowledge and resource
pooling
• Forging consensus on
policy, strategy,
programmatic responses,
and international norms and standards, including norms
with which
intergovernmental
organizations increasingly
align
• Positioning health and
specific health issues at the
core of national and global
development agendas
• Increasing the visibility of
and mobilizing
unprecedented resources,
including demand-driven
donor support for neglected
health issues through
powerful advocacy,
communications campaigns,
and innovative financing
mechanisms
• Expanding the availability of
and access to free or
• Identify and play to the partnerships’
comparative advantage: GHP must be
able to demonstrate that the joint
work uniquely positions it to address
an unfilled yet critical gap. GHP must
define its value through goals and its
distinct contribution and comparative
advantage to achieve those goals.
• Adequately resource partnership
secretariats: The size of the secretariat
is a critical factor in determining its success given its role to coordinate
partners.
• Practice good management: Nearly
all evaluations found deficiencies in
GHP management. As GHPs grow,
professional management structures
and strategies become increasingly
critical to optimize partner
performance, monitoring, and
accountability.
• Practice good governance: Boards
should be representative of
stakeholders. Transparency helps to
highlight gaps, facilitates the receipt of
input and feedback from partners, and
promotes efficiency in service delivery.
A formal system of partner
accountability is needed to effectively
communicate roles, objectives, and
responsibilities.
• Acknowledge and respect partners’
• Need more sustained critical
reflection and independent evaluation
to achieve optimal results given the
level of resources that collaboration
demands.
• Need to discuss the benefit of
opening up spaces for public debate
of evaluation findings.
• Apply lessons learned more widely
across and within partnerships.
41 Mapping Global Leadership in Child Health
No Author and
date Title
Global health
partnerships (GHPs)
assessed
Contributions Challenges and lessons learned Next steps and
recommendations
reduced cost, quality-assured
medicines and vaccines,
particularly for neglected
diseases, in low- and middle-
income countries through
the mobilization of R&D,
large scale funding, improved
distribution networks and
revisions to international
trade and intellectual
property regulations
• Strengthening health
systems and national health
policy processes, although
not uniformly or sufficiently
systematically
• Transforming the way
many international health
organizations fulfil their
mandates, particularly
through pressure to improve transparency and
accountability and to
minimize duplication of
activities
diverse interests: Lack of
understanding or appreciation of the
pressures and incentives faced by
partners is a significant barrier to
collaboration.
• Ensure operations impact positively
on national and local systems: GHP
needs to increasingly differentiate its
approaches in specific countries and
needs to focus more on capacity-
building.
• Strive for continuous improvement:
GHP should regard itself more as a
learning process rather than an
organizational structure.
3 Caines
(2004)
Assessing the impact of
global health partnerships
Some GHPs are trying to
define their added value
more precisely, which
include:
• Harnessing high-quality
talent from disparate
sources;
• Enhancing the capability of
partners through
coordination and consensus
building;
• Ensuring resource
knowledge management,
identifying funding gaps and
priorities, mobilizing
resource, and funding
additional support to
countries for supplies and
• GHPs are generally seen as having a
positive impact. GHPs are seen as a
fruitful way to foster research and
development for diagnostics, drugs,
etc.
• The proliferation of multiple GHPs
runs the risk of overwhelming country
capacity and a health system that is
weak. Thus, governance needs to be
addressed as well as the performance
of impact assessments.
• GHPs need to tighten focus on
securing propoverty and gender-
related objectives. GHPs should play a
role in advocating for and stimulating
appropriate policies and approaches.
• Resource availability raises key issues
about sustainability, predictability, and
Recommendations (for Department
for International Development
[DFID]):
• The developing nature of the GHP
approach provides an additional
rationale for periodic monitoring and
evaluation, not only of individual
GHPs but, more crucially, of the
GHPs’ collective impact, especially at
country level.
• Donors such as DFID who support
both GHPs and direct national and
sector budget aids should lobby for
funding GHPs (GFATM and GAVI) to
provide monies within sector-wide
approaches (SWAps) or basket-fund
frameworks, where these exist.
• DFID should encourage relevant
42 Mapping Global Leadership in Child Health
No Author and
date Title
Global health
partnerships (GHPs)
assessed
Contributions Challenges and lessons learned Next steps and
recommendations
operational costs;
• Innovating in processes and
actions, and creating synergy
between new developments
and implementation; and
• Providing consistent high-
profile advocacy and broadly
spread communications.
macroeconomic stability.
• The complexity of GHPs raise
concerns about institutional issues at
the global level. Thus, there is a need
for increased transparency,
representation of partners and
stakeholders on governing bodies, and
the performance of achievement
assessments. Governance mechanisms
at the country level should also be
assessed.
GHPs to work with country partners
to harmonize multiple HIV/AIDS GHP
programs (where they exist in
country) as well as seek to influence
directly all those concerned in the
initiatives.
• Strategic, operational, and business
plans that clearly define roles and
responsibilities of all major partners
should be developed and periodically
reviewed as a criterion for DFID
engagement with particular GHPs.
DFID should advocate for and
participate in promising initiatives to
consolidate work planning among
GHPs.
4 Lu et al.
(2006)
Effect of GAVI
on diphtheria, tetanus,
and pertussis vaccine
coverage: an
independent assessment
GAVI • For countries with higher than 65%
diphtheria-tetanus-pertussis (DPT)
vaccine coverage, GAVI spending had
no positive effect on vaccine coverage,
but, for countries with a baseline lower than 65%, GAVI contributed to
increased coverage.
• It is estimated that GAVI spends USD
8.40–20.00 per child for immunization.
• Country behavior, with respect to
receiving GAVI funds, was likely
affected by the prospect that reward
payments would begin in the 4th year
of the projects.
• Public-private partnerships can help
reverse negative trends in public
health.
• It is too early to determine if the
effort will be sustainable by replacing
GAVI funding with national
expenditures.
• Current and future success of GAVI
are linked to the capacity to measure
the output of immunization programs
through changes in coverage.
Performance-based disbursements
should be carefully analyzed in the
coming years so that more countries
can be observed during the reward
phase of GAVI funding.
5 McCoy et The Bill & Melinda Gates The Bill & Melinda Gates • Despite a long history of • Size of individual grants varied • Explore governance by looking at
43 Mapping Global Leadership in Child Health
No Author and
date Title
Global health
partnerships (GHPs)
assessed
Contributions Challenges and lessons learned Next steps and
recommendations
al. (2009) Foundation’s grant-
making
program for global health
Foundation (BMGF) private, philanthropic global
health funding, the influence
made by BMFG is on a
different order than what
has been seen through the
efforts of other private
donors in the field.
• The amount spent on
global health by BMFG was
almost as much as the
World Health Organization’s
annual budget (about USD
1.65 billion).
• Such spending is evident in
malaria research, which has
tripled due to the influence
of BMGF.
substantially, and 65% of funding was
shared by 20 organizations; the largest
amount of funding was awarded to
nongovernmental organizations
(NGOs) and nonprofit organizations.
• Other major recipients included
public awareness and advocacy
organizations.
• BMGF Also funded several think
tanks or policy research institutes.
• Government agencies and for-profit
companies were infrequent recipients
of BMGF grants.
• From 1998–2007, 75% of all global
health funding was allocated to six
categories: HIV/AIDS, malaria, vaccine-
preventable diseases, child health, TB,
and tropical and neglected diseases.
• BMGF has helped promote the
emergence of loose, horizontal
networks where it is unclear who is making decisions and who is
accountable to whom.
• BMFG’s emphasis on technology can
detract attention from social
determinants of health while
promoting an approach to health
improvement that is highly dependent
on clinical technologies.
the effect of BMGF on World Bank,
World Health Organization (WHO),
and other key GHPs.
• Further research is needed to assess
the cost-effectiveness of BMGF’s
approaches, strategies, and
investments for improving the health
of the poor.
6 BMGF and
McKinsey &
Company
(2005)
Global health
partnerships:
Assessing country
consequences
Gains made my GHPs may have come
at a cost because of the introduction
of vertically oriented resources into a
horizontally organized health system.
This, paired with resource strained
environments, leads to two likely
consequences for countries:
• Countries struggle to absorb
resources from GHPs because they
are not provided with adequate
support (technical and other) to
effectively implement programming;
and
• Because GHPs often bypass country
GHPs need to ensure that their
grants are accompanied with
adequate resources by:
• Allowing countries to lead
discussions on optimal timing, pace,
and scale of new technology adoption
and policies;
• Allowing countries to include
overhead costs in grants to provide
implementation support;
• Providing searchable database of
technical assistance (TA) solutions
and providers; and
• Providing administrative support for
44 Mapping Global Leadership in Child Health
No Author and
date Title
Global health
partnerships (GHPs)
assessed
Contributions Challenges and lessons learned Next steps and
recommendations
processes that are already in place,
countries are burdened with parallel
and duplicative processes from
multiple GHPs.
•GHPs have not adequately or
effectively communicated with
countries and partners. They do not
adequately support shifts in policy and
technology or provide adequate
implementation assistance.
• GHPs have created too many
country coordination forums, which
are inadequately structured, thereby
rendering them generally ineffective.
• The GHP’s ‘one size fits all’ approach
does not recognize country diversity,
thereby causing GPHs difficulties when
dealing with system-level issues.
• Communication is poor, and partners
are often unclear about their roles and
responsibilities.
coordinating mechanisms.
GHPs should design their processes
and systems to complement those
that countries already have in place
by:
• Being flexible with countries that
demonstrated good track records;
• Collaborating with other GHPs to
ask countries for one, unified, and
multiyear health sector plan; and
• Creating a single, unified mission and
a single, unified report in each disease
area to reduce the burden on country
officials.
GHPs should create a minimum set of
communication norms.
7 Sidlibe et
al. (2006)
The Global Fund (GF) at
five: what next for
universal access for
HIV/AIDS, TB, and
malaria?
• In its first 5 years, the GF
for AIDS, TB, and Malaria
had the ability to make
grants in nearly all
developing countries, had
the operational capacity to
move swiftly and
transparently in approving
proposals, engaged in direct
involvement with civil
society, and had the capacity
for critical introspection,
which led to country-level
success.
• Maintaining sustainable funding is
likely to be an issue for GF. It currently
has difficulties meeting the more
modest resource requirements derived
from historic levels of new grant
approvals and renewals.
• Beyond cash contributions, the
private sector should be encouraged
to provide services in kind to GF, such
as costing forecasts, risk assessments,
and information technology support.
• Governments and civil society
organizations of developing countries
will need to be more involved in the
process of fundraising.
• GF must seek creative and proactive
public demands for the money it raises;
countries need to be part of the
negotiation process.
• GF’s speedy allocations and
disbursement of resources can be
• GF needs to carefully and creatively
reconsider its strategy for mobilizing
sustainable resources of funding.
• GF must lobby countries more
actively to contribute more funds
indirectly (reducing taxes) or directly.
• Countries will need to find technical
assistance for developing and
implementing GF grants.
• It is unclear, but GF may need to set
up its own technical assistance facility.
• GF’s efforts may be better placed in
strengthening leadership and
relationships at the country level.
• GF needs to address concerns
voiced by countries that
performance-based financing is a
punitive mechanism.
• GF should attempt to design the
framework and necessary
performance metrics to evaluate its
45 Mapping Global Leadership in Child Health
No Author and
date Title
Global health
partnerships (GHPs)
assessed
Contributions Challenges and lessons learned Next steps and
recommendations
attributed to GF’s decision to stay out
of implementation efforts.
• The capacity of many traditional
providers is not equal to the scale of
financial resources currently available
for operation, and, thus, the
complexity of TA has increased.
• There is debate over whether GF
should focus on health system
strengthening.
• GF has two key efforts: improve the
size and effectiveness of funds and
harmonize and align with national plans
and priorities; and ensure long-term
credibility by further engaging
countries in mobilizing their own
funds.
own performance.
8 Hoffman et
al. (2015)
Mapping global health
architecture to inform
the future
• Majority of actors identified in global health system are NGOs, but the largest
actor is in the form of public-private partnerships.
• US is the most popular location for global health actor headquarters (namely
New York City and Washington, DC). • Over 60% of global health actors list improving health as their primary intent.
• The creation of new global health actors has occurred in waves: 1940–1959,
1970–89, and 1990–2009.
• WHO continues to play a major leadership role in the stewardship of global
health, which is being challenged by an ever-shrinking budget.
• Few global health actors are involved in cross-sectoral advocacy. This is likely
to become more in the post-2015 era due to an increasingly interconnected
global community.
• Global health actors are involved in sharing intellectual property and in
harmonizing norms, standards, and guidelines.
• Global health actors are increasingly more involved in the management of
externalities.
• The number of global health actors engaged in direct country assistance has
increased since the 1990s, in accordance with the increase in funding.
9 Moon et al.
(2010)
The global health system:
Lessons for a stronger
institutional framework
• Previously, global agenda-
setting took place within the
framework of UN with input
from a few foundations and
national governments.
• In the past, international
resources flowed primarily
• Coordination is essential, but few
organizations wish to be coordinated
because of the loss of autonomy and
associated costs.
• There is a current governance gap
within the existing system; there are
no clear norms for how resources
• Investments in human capital are
essential but take many years to
generate fruitful results. This long-
term commitment of UNICEF,
UNDP, World Bank, and WHO is
key.
• There is a need for greater training
46 Mapping Global Leadership in Child Health
No Author and
date Title
Global health
partnerships (GHPs)
assessed
Contributions Challenges and lessons learned Next steps and
recommendations
through bilateral or
multilateral donations and
WHO.
• GFATM attempts to lighten
the burden on national
health systems by reporting
requirements and lack of
coordination among multiple
donors. This lack of
coordination has been
exacerbated by a recent
increase in the number of
players in the global health
system.
should be allocated across different
health needs.
• Long-term sustainability of funding is
dependent on: demonstrating results;
making financial arrangements more
politically acceptable; developing
innovative financing mechanisms; which
are less vulnerable to the politicized
budgeting processes.
• There has been a resurgence in R&D
targeted at developing new tools for
health needs.
• Significant improvements in health
outcomes (in some countries) can be
attributed to leadership, community
involvement, district-level focus, use of
data to set priorities, and the
prioritization of equitable access.
• Despite the increase in funds to
expand programs, there is little spent
on operational research and determining what works where.
• Effective M&E requires that efforts
achieve technical credibility, maintain
legitimacy, and produce knowledge
that is salient for end-users.
• No single actor can or should set the
agenda for action in global health.
• Sustainability depends on
strengthening national health systems.
• Proliferation of global actors
threatens to weaken health systems by
placing additional reporting burdens on
them.
• It is critical to support research that
provides the evidence and knowledge
base for prioritization, resource
allocation, and the development and
evaluation of new tools and
interventions.
in lab sciences, health economics,
management, program evaluation, and
implementation research.
• There should be a greater emphasis
on building the capacity of
researchers and research
organizations in developing countries.
• A comprehensive, operational and
policy research agenda is needed to
fully understand those policies or
practices that best strengthen national
health systems.
• There needs to be sufficient
investment in M&E, and M&E should
be an integral part of all program
planning.
10 Mokoro
Limited
Independent
comprehensive evaluation
Scaling Up Nutrition
(SUN)
SUN added value with its
objective to enable the
• The picture is mixed in terms of
SUN’s direct effect on national-level
47 Mapping Global Leadership in Child Health
No Author and
date Title
Global health
partnerships (GHPs)
assessed
Contributions Challenges and lessons learned Next steps and
recommendations
(2014) of the scaling up nutrition
movement
environment, which
included:
• Aligning stakeholders for
the rapid scale-up of
selective evidence-based
policies and interventions
that enhance nutrition and
joint action; and
• Facilitating and convening
of stakeholders to broker
interactions within and
across SUN countries and
networks.
SUN added value with its
practice of sharing, which
included:
• Identifying and sharing
evidence-based good
practices to enable the
prioritization of actions and resources; and
• Promoting women’s
empowerment and
emphasizing gender
approaches to
undernutrition that enable a
transformative effect on
sustainable nutrition
security.
SUN added value through its
aligned actions, which
included:
• Accepting and
implementing mutual
accountability on behalf of
intended beneficiaries; and
• Tracking and evaluating
performance to provide
better understanding of
impact drivers.
nutrition policies and plans. Some
areas show SUNs relatively minimal
traction on policy change while other
cases clearly highlight the attention
SUN has brought to nutrition and its
influence on the adoption of
approaches.
• SUN’s movement has a strong focus
on being country-centered. It
emphasizes support for government-
led plans and has deliberately avoided
being prescriptive about the structure
or the content of those plans.
• In terms of organization and
governance, there is a case for a
smaller executive body that might be
more effective and efficient in holding
parties accountable.
Required support to SUN countries
• Advocacy and convening stakeholders
• Technical support
• Standard-setting and monitoring
• Financial support
48 Mapping Global Leadership in Child Health
No Author and
date Title
Global health
partnerships (GHPs)
assessed
Contributions Challenges and lessons learned Next steps and
recommendations
SUN added value through
increased resources, which
included:
• Advocating to increase
political commitment and
mobilizing resources that
enable the scale-up to
improve nutrition.
References
1. Acuin, Cecilia S, Geok Lin Khor, Tippawan Liabsuetrakul, Endang L Achadi, Thein Thein Htay,
Rebecca Firestone, and Zulfiqar A Bhutta. “Maternal, Neonatal, and Child Health in Southeast
Asia: Towards Greater Regional Collaboration.” The Lancet 377, no. 9764 (February 2011): 516–
25. doi:10.1016/S0140-6736(10)62049-1.
2. Adams, Alayne M, Atonu Rabbani, Shamim Ahmed, Shehrin Shaila Mahmood, Ahmed Al-Sabir,
Sabina F Rashid, and Timothy G Evans. “Explaining Equity Gains in Child Survival in Bangladesh:
Scale, Speed, and Selectivity in Health and Development.” The Lancet 382, no. 9909 (December
2013): 2027–37. doi:10.1016/S0140-6736(13)62060-7.
3. Agarwal, Koki, Nancy Caiola, and Anita Gibson. “Best Practices for a Successful MNCH
Partnership That an External Evaluation Could Never Find: Experiences from the Maternal and
Child Health Integrated Program.” International Journal of Gynaecology and Obstetrics: The
Official Organ of the International Federation of Gynaecology and Obstetrics 130 Suppl 2 (June
2015): S11–16. doi:10.1016/j.ijgo.2015.04.001.
4. Arifeen, Shams El, Lauren S Blum, D M Emdadul Hoque, Enayet K Chowdhury, Rasheda Khan,
Robert E Black, Cesar G Victora, and Jennifer Bryce. “Integrated Management of Childhood
Illness (IMCI) in Bangladesh: Early Findings from a Cluster-Randomised Study.” The Lancet 364,
no. 9445 (n.d.): 1595–1602. doi:10.1016/S0140-6736(04)17312-1.
5. Arregoces, Leonardo, Felicity Daly, Catherine Pitt, Justine Hsu, Melisa Martinez-Alvarez, Giulia
Greco, Anne Mills, Peter Berman, and Josephine Borghi. “Countdown to 2015: Changes in Official
Development Assistance to Reproductive, Maternal, Newborn, and Child Health, and Assessment
of Progress between 2003 and 2012.” The Lancet Global Health 3, no. 7 (July 2015): e410–21.
doi:10.1016/S2214-109X(15)00057-1.
6. Becerra-Posada, Francisco. “Health in All Policies: A Strategy to Support the Sustainable
Development Goals.” The Lancet Global Health 3, no. 7 (July 2015): e360. doi:10.1016/S2214-
109X(15)00040-6.
7. Berlan, David. “Pneumonia’s Second Wind? A Case Study of the Global Health Network for
Childhood Pneumonia.” Health Policy and Planning, October 5, 2015, czv070.
doi:10.1093/heapol/czv070.
8. Beyeza-Kashesya, Jolly, Frank Kaharuza, and Daniel Murokora. “The Advantage of Professional
Organizations as Advocates for Improved Funding of Maternal and Child Health Services in
Uganda.” International Journal of Gynaecology and Obstetrics: The Official Organ of the
International Federation of Gynaecology and Obstetrics 127 Suppl 1 (October 2014): S52–55.
doi:10.1016/j.ijgo.2014.07.013.
50 Mapping Global Leadership in Child Health
9. Bhutta, Zulfiqar A. “Global Child Survival: Beyond Numbers.” The Lancet 379, no. 9832 (June
2012): 2126–28. doi:10.1016/S0140-6736(12)60686-2.
10. Bhutta, Zulfiqar A, Tahmeed Ahmed, Robert E Black, Simon Cousens, Kathryn Dewey, Elsa
Giugliani, Batool A Haider, et al. “What Works? Interventions for Maternal and Child
Undernutrition and Survival.” The Lancet 371, no. 9610 (February 2008): 417–40.
doi:10.1016/S0140-6736(07)61693-6.
11. Bhutta, Zulfiqar A., Samana Ali, Simon Cousens, Talaha M. Ali, Batool Azra Haider, Arjumand
Rizvi, Pius Okong, Shereen Z. Bhutta, and Robert E. Black. “Alma-Ata: Rebirth and Revision 6
Interventions to Address Maternal, Newborn, and Child Survival: What Difference Can Integrated
Primary Health Care Strategies Make?” Lancet (London, England) 372, no. 9642 (September 13,
2008): 972–89. doi:10.1016/S0140-6736(08)61407-5.
12. Bhutta, Zulfiqar A, Samana Ali, Simon Cousens, Talaha M Ali, Batool Azra Haider, Arjumand
Rizvi, Pius Okong, Shereen Z Bhutta, and Robert E Black. “Interventions to Address Maternal,
Newborn, and Child Survival: What Difference Can Integrated Primary Health Care Strategies
Make?” The Lancet 372, no. 9642 (September 19, 2008): 972–89. doi:10.1016/S0140-
6736(08)61407-5.
13. Bhutta, Zulfiqar A, and Mickey Chopra. “Moving Ahead: What Will a Renewed Countdown to
2030 for Women and Children Look Like?” The Lancet, October 2015. doi:10.1016/S0140-
6736(15)00527-9.
14. Bhutta, Zulfiqar A, Mickey Chopra, Henrik Axelson, Peter Berman, Ties Boerma, Jennifer Bryce,
Flavia Bustreo, et al. “Countdown to 2015 Decade Report (2000–10): Taking Stock of Maternal,
Newborn, and Child Survival.” The Lancet 375, no. 9730 (June 2010): 2032–44.
doi:10.1016/S0140-6736(10)60678-2.
15. Bhutta, Zulfiqar A, Jai K Das, Rajiv Bahl, Joy E Lawn, Rehana A Salam, Vinod K Paul, M Jeeva
Sankar, et al. “Can Available Interventions End Preventable Deaths in Mothers, Newborn Babies,
and Stillbirths, and at What Cost?” The Lancet 384, no. 9940 (July 2014): 347–70.
doi:10.1016/S0140-6736(14)60792-3.
16. Bhutta, Zulfiqar A, Jai K Das, Arjumand Rizvi, Michelle F Gaffey, Neff Walker, Susan Horton,
Patrick Webb, Anna Lartey, and Robert E Black. “Evidence-Based Interventions for Improvement
of Maternal and Child Nutrition: What Can Be Done and at What Cost?” The Lancet 382, no. 9890
(August 2013): 452–77. doi:10.1016/S0140-6736(13)60996-4.
17. Bhutta, Zulfiqar A., Jai K. Das, Neff Walker, Arjumand Rizvi, Harry Campbell, Igor Rudan, Robert
E. Black, and Lancet Diarrhoea and Pneumonia Interventions Study Group. “Interventions to
Address Deaths from Childhood Pneumonia and Diarrhoea Equitably: What Works and at What
Cost?” Lancet (London, England) 381, no. 9875 (April 20, 2013): 1417–29. doi:10.1016/S0140-
6736(13)60648-0.
18. Bill & Melinda Gates Foundation. “Global Health Partnerships: Assessing Country Consequences,”
n.d.
Page |
April 2016
51
19. Black, Robert E, Simon Cousens, Hope L Johnson, Joy E Lawn, Igor Rudan, Diego G Bassani,
Prabhat Jha, et al. “Global, Regional, and National Causes of Child Mortality in 2008: A Systematic
Analysis.” The Lancet 375, no. 9730 (June 2010): 1969–87. doi:10.1016/S0140-6736(10)60549-1.
20. Black, Robert E, and Shams El Arifeen. “Community-Based Treatment of Severe Childhood
Pneumonia.” The Lancet 379, no. 9817 (n.d.): 692–94. doi:10.1016/S0140-6736(11)61843-6.
21. Black, Robert E, Saul S Morris, and Jennifer Bryce. “Where and Why Are 10 Million Children
Dying Every Year?” The Lancet 361, no. 9376 (June 2003): 2226–34. doi:10.1016/S0140-
6736(03)13779-8.
22. Black, Robert E, Cesar G Victora, Susan P Walker, Zulfiqar A Bhutta, Parul Christian, Mercedes de
Onis, Majid Ezzati, et al. “Maternal and Child Undernutrition and Overweight in Low-Income and
Middle-Income Countries.” The Lancet 382, no. 9890 (August 2013): 427–51. doi:10.1016/S0140-
6736(13)60937-X.
23. Bryce, Jennifer, Cynthia Boschi-Pinto, Kenji Shibuya, and Robert E Black. “WHO Estimates of the
Causes of Death in Children.” The Lancet 365, no. 9465 (March 2005): 1147–52.
doi:10.1016/S0140-6736(05)71877-8.
24. Bryce, Jennifer, Denise Coitinho, Ian Darnton-Hill, David Pelletier, and Per Pinstrup-Andersen.
“Maternal and Child Undernutrition: Effective Action at National Level.” The Lancet 371, no. 9611
(February 2008): 510–26. doi:10.1016/S0140-6736(07)61694-8.
25. Bryce, Jennifer, Shams el Arifeen, George Pariyo, ClaudioF Lanata, Davidson Gwatkin, Jean-Pierre
Habicht, and Multi-Country Evaluation of IMCI Study Group. “Reducing Child Mortality: Can
Public Health Deliver?” Lancet (London, England) 362, no. 9378 (July 12, 2003): 159–64.
26. Bryce, Jennifer, Nancy Terreri, Cesar G Victora, Elizabeth Mason, Bernadette Daelmans, Zulfiqar
A Bhutta, Flavia Bustreo, Francisco Songane, Peter Salama, and Tessa Wardlaw. “Countdown to
2015: Tracking Intervention Coverage for Child Survival.” The Lancet 368, no. 9541 (n.d.): 1067–
76. doi:10.1016/S0140-6736(06)69339-2.
27. Bryce, Jennifer, and Cesar G Victora. “Child Survival: Countdown to 2015.” The Lancet 365, no.
9478 (n.d.): 2153–54. doi:10.1016/S0140-6736(05)66752-9.
28. Bryce, Jennifer, Cesar G Victora, and Robert E Black. “The Unfinished Agenda in Child Survival.”
The Lancet 382, no. 9897 (September 2013): 1049–59. doi:10.1016/S0140-6736(13)61753-5.
29. Buse, Kent, and Andrew M. Harmer. “Seven Habits of Highly Effective Global Public-Private
Health Partnerships: Practice and Potential.” Social Science & Medicine (1982) 64, no. 2 (January
2007): 259–71. doi:10.1016/j.socscimed.2006.09.001.
30. Buse, Kent, and Sonja Tanaka. “Global Public-Private Health Partnerships: Lessons Learned from
Ten Years of Experience and Evaluation.” International Dental Journal 61 (August 1, 2011): 2–10.
doi:10.1111/j.1875-595X.2011.00034.x.
52 Mapping Global Leadership in Child Health
31. Caines, Karen. “Assessing the Impact of Global Health Partnerships.” DFID Health Resource
Centre, 2006.
32. Carrera, Carlos, Adeline Azrack, Genevieve Begkoyian, Jerome Pfaffmann, Eric Ribaira, Thomas
O’Connell, Patricia Doughty, et al. “The Comparative Cost-Effectiveness of an Equity-Focused
Approach to Child Survival, Health, and Nutrition: A Modelling Approach.” The Lancet 380, no.
9850 (October 2012): 1341–51. doi:10.1016/S0140-6736(12)61378-6.
33. “Children’s Health Priorities and Interventions | The BMJ.” Accessed November 21, 2015.
http://www.bmj.com/content/351/bmj.h4300.
34. Chopra, Mickey, Emmanuelle Daviaud, Robert Pattinson, Sharon Fonn, and Joy E Lawn. “Saving
the Lives of South Africa’s Mothers, Babies, and Children: Can the Health System Deliver?” The
Lancet 374, no. 9692 (September 2009): 835–46. doi:10.1016/S0140-6736(09)61123-5.
35. Chopra, Mickey, Elizabeth Mason, John Borrazzo, Harry Campbell, Igor Rudan, Li Liu, Robert E
Black, and Zulfiqar A Bhutta. “Ending of Preventable Deaths from Pneumonia and Diarrhoea: An
Achievable Goal.” The Lancet 381, no. 9876 (n.d.): 1499–1506. doi:10.1016/S0140-
6736(13)60319-0.
36. Chopra, Mickey, Alyssa Sharkey, Nita Dalmiya, David Anthony, and Nancy Binkin. “Strategies to
Improve Health Coverage and Narrow the Equity Gap in Child Survival, Health, and Nutrition.”
The Lancet 380, no. 9850 (October 2012): 1331–40. doi:10.1016/S0140-6736(12)61423-8.
37. “Countdown to 2015 for Maternal, Newborn, and Child Survival: The 2008 Report on Tracking
Coverage of Interventions.” The Lancet 371, no. 9620 (n.d.): 1247–58. doi:10.1016/S0140-
6736(08)60559-0.
38. Dalglish, Sarah L., Asha George, Jessica C. Shearer, and Sara Bennett. “Epistemic Communities in
Global Health and the Development of Child Survival Policy: A Case Study of iCCM.” Health
Policy and Planning 30, no. suppl 2 (December 1, 2015): ii12–25. doi:10.1093/heapol/czv043.
39. Darmstadt, Gary L., Jeremy Shiffman, and Joy E. Lawn. “Advancing the Newborn and Stillbirth
Global Agenda: Priorities for the next Decade.” Archives of Disease in Childhood 100 Suppl 1
(February 2015): S13–18. doi:10.1136/archdischild-2013-305557.
40. Dean, Sohni, Igor Rudan, Fernando Althabe, Aimee Webb Girard, Christopher Howson, Ana
Langer, Joy Lawn, et al. “Setting Research Priorities for Preconception Care in Low- and Middle-
Income Countries: Aiming to Reduce Maternal and Child Mortality and Morbidity.” PLOS Med 10,
no. 9 (September 3, 2013): e1001508. doi:10.1371/journal.pmed.1001508.
41. Dedoose, Web Application for Managing, Analyzing, and Presenting Qualitative and Mixed
Method Research Data (version 6.1.18). Los Angeles, CA: SocioCultural Research Consultants,
LLC, 2015. www.dedoose.com.
42. Desalegn, Hailemariam, Erna Solberg, and Jim Yong Kim. “The Global Financing Facility:
Country Investments for Every Woman, Adolescent, and Child.” The Lancet 386, no. 9989 (July
2015): 105–6. doi:10.1016/S0140-6736(15)61224-7.
Page |
April 2016
53
43. Díaz-Martínez, Elisa, and Elizabeth D. Gibbons. “The Questionable Power of the Millennium
Development Goal to Reduce Child Mortality.” Journal of Human Development and Capabilities
15, no. 2–3 (July 3, 2014): 203–17. doi:10.1080/19452829.2013.864621.
44. Dickson, Kim E, Aline Simen-Kapeu, Mary V Kinney, Luis Huicho, Linda Vesel, Eve Lackritz,
Joseph de Graft Johnson, et al. “Every Newborn: Health-Systems Bottlenecks and Strategies to
Accelerate Scale-up in Countries.” The Lancet 384, no. 9941 (August 2014): 438–54.
doi:10.1016/S0140-6736(14)60582-1.
45. Dieleman JL, Graves C, Johnson E, and et al. “Sources and Focus of Health Development
Assistance, 1990–2014.” JAMA 313, no. 23 (June 16, 2015): 2359–68.
doi:10.1001/jama.2015.5825.
46. Duke, Trevor. “Child Survival and IMCI: In Need of Sustained Global Support.” The Lancet 374,
no. 9687 (n.d.): 361–62. doi:10.1016/S0140-6736(09)61396-9.
47. Easterly, Willim. “How the Millennium Development Goals Are Unfair to Africa.” World
Development 37, no. 1 (2009): 26–35.
48. El Arifeen, Shams, Aliki Christou, Laura Reichenbach, Ferdous Arfina Osman, Kishwar Azad,
Khaled Shamsul Islam, Faruque Ahmed, Henry B Perry, and David H Peters. “Community-Based
Approaches and Partnerships: Innovations in Health-Service Delivery in Bangladesh.” The Lancet
382, no. 9909 (December 2013): 2012–26. doi:10.1016/S0140-6736(13)62149-2.
49. Engle, Patrice L, Lia CH Fernald, Harold Alderman, Jere Behrman, Chloe O’Gara, Aisha
Yousafzai, Meena Cabral de Mello, et al. “Strategies for Reducing Inequalities and Improving
Developmental Outcomes for Young Children in Low-Income and Middle-Income Countries.” The
Lancet 378, no. 9799 (October 2011): 1339–53. doi:10.1016/S0140-6736(11)60889-1.
50. “Every Newborn: Health-Systems Bottlenecks and Strategies to Accelerate Scale-up in Countries -
The Lancet.” Accessed October 28, 2015.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60582-1/abstract.
51. Every Woman Every Child. “Commitments in Support of the Global Strategy for Women’s,
Children’s and Adolescents’ Health (2016- 2030),” 2015. http://who.int/life-course/partners/global-
strategy/globalstrategyreport2016-2030-lowres.pdf.
52. United Nations Secretary General. “The Global Strategy for Women’s and Children’s Health.”
United Nations, 2010.
53. Fay, Marianne, Danny Leipziger, Quentin Wodon, and Tito Yepes. “Achieving Child-Health-
Related Millennium Development Goals: The Role of Infrastructure.” World Development 33, no. 8
(August 2005): 1267–84. doi:10.1016/j.worlddev.2005.03.001.
54. George, Asha, Daniela C. Rodríguez, Kumanan Rasanathan, Neal Brandes, and Sara Bennett.
“iCCM Policy Analysis: Strategic Contributions to Understanding Its Character, Design and Scale
up in Sub-Saharan Africa.” Health Policy and Planning 30, no. suppl 2 (December 1, 2015): ii3–
11. doi:10.1093/heapol/czv096.
54 Mapping Global Leadership in Child Health
55. Gill, Christopher J, Mark Young, Kate Schroder, Liliana Carvajal-Velez, Marion McNabb, Samira
Aboubaker, Shamim Qazi, and Zulfiqar A Bhutta. “Bottlenecks, Barriers, and Solutions: Results
from Multicountry Consultations Focused on Reduction of Childhood Pneumonia and Diarrhoea
Deaths.” The Lancet 381, no. 9876 (April 2013): 1487–98. doi:10.1016/S0140-6736(13)60314-1.
56. Global Financing Facility. “Global Financing Facility in Support of Every Woman Every Child
Business Plan,” September 18, 2015.
https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja&uact=8&ved=
0ahUKEwjWu_z90J_MAhVMGx4KHbn6A-
8QFgglMAE&url=http%3A%2F%2Fwww.worldbank.org%2Fcontent%2Fdam%2FWorldbank%2
Fdocument%2FHDN%2FHealth%2FGFFExecutiveSummaryFINAL.pdf&usg=AFQjCNFFVyGc-
l0ts7gPIyaXUrYKtEnOKw&sig2=DBd0J2Obesbm8kNaUYOgZQ.
57. Goh, Nancy, and Katherine Pollak. “Progress over a Decade of Zinc and ORS Scale-up: Best
Practices and Lessons Learned,” February 2016.
58. Grantham-McGregor, Sally, Yin Bun Cheung, Santiago Cueto, Paul Glewwe, Linda Richter, and
Barbara Strupp. “Developmental Potential in the First 5 Years for Children in Developing
Countries.” The Lancet 369, no. 9555 (January 2007): 60–70. doi:10.1016/S0140-6736(07)60032-4.
59. Greco, Giulia, Timothy Powell-Jackson, Josephine Borghi, and Anne Mills. “Countdown to 2015:
Assessment of Donor Assistance to Maternal, Newborn, and Child Health between 2003 and 2006.”
The Lancet 371, no. 9620 (n.d.): 1268–75. doi:10.1016/S0140-6736(08)60561-9.
60. Gwatkin, Davidson R, Abbas Bhuiya, and Cesar G Victora. “Making Health Systems More
Equitable.” The Lancet 364, no. 9441 (October 2004): 1273–80. doi:10.1016/S0140-
6736(04)17145-6.
61. Haines, Andy. “Development Assistance for Health: Potential Contribution to the Post-2015
Agenda.” JAMA 313, no. 23 (June 16, 2015): 2328–30. doi:10.1001/jama.2015.5790.
62. Haines, Andy, David Sanders, Uta Lehmann, Alexander K Rowe, Joy E Lawn, Steve Jan, Damian
G Walker, and Zulfiqar Bhutta. “Achieving Child Survival Goals: Potential Contribution of
Community Health Workers.” The Lancet 369, no. 9579 (n.d.): 2121–31. doi:10.1016/S0140-
6736(07)60325-0.
63. Hoffman, Steven J., Clark B. Cole, and Mark Pearcey. “Mapping Global Health Architecture to
Inform the Future.” Centre on Global Health Security, January 2015.
64. Horton, Richard. “A New Global Commitment to Child Survival.” The Lancet 368, no. 9541 (n.d.):
1041–42. doi:10.1016/S0140-6736(06)69331-8.
65. Horton, Richard. “UNICEF Leadership 2005–2015: A Call for Strategic Change.” The Lancet 364,
no. 9451 (n.d.): 2071–74. doi:10.1016/S0140-6736(04)17560-0.
66. Hsu, Justine, Catherine Pitt, Giulia Greco, Peter Berman, and Anne Mills. “Countdown to 2015:
Changes in Official Development Assistance to Maternal, Newborn, and Child Health in 2009-10,
Page |
April 2016
55
and Assessment of Progress since 2003.” Lancet (London, England) 380, no. 9848 (September 29,
2012): 1157–68. doi:10.1016/S0140-6736(12)61415-9.
67. IHME. “Development Assistance for Health Database 1990-2015.” Accessed April 19, 2016.
http://ghdx.healthdata.org/record/development-assistance-health-database-1990-2015.
68. Jones, Gareth, Richard W. Steketee, Robert E. Black, Zulfiqar A. Bhutta, Saul S. Morris, and
Bellagio Child Survival Study Group. “How Many Child Deaths Can We Prevent This Year?”
Lancet (London, England) 362, no. 9377 (July 5, 2003): 65–71. doi:10.1016/S0140-
6736(03)13811-1.
69. Joshi, Devin K., Barry B. Hughes, and Timothy D. Sisk. “Improving Governance for the Post-2015
Sustainable Development Goals: Scenario Forecasting the Next 50 Years.” World Development 70
(June 2015): 286–302. doi:10.1016/j.worlddev.2015.01.013.
70. Kirton, John, Julia Kulik, and Caroline Bracht. “The Political Process in Global Health and
Nutrition Governance: The G8’s 2010 Muskoka Initiative on Maternal, Child, and Newborn
Health.” Annals of the New York Academy of Sciences 1331 (December 2014): 186–200.
doi:10.1111/nyas.12494.
71. “Knowledge into Action for Child Survival.” The Lancet 362, no. 9380 (July 2003): 323–27.
doi:10.1016/S0140-6736(03)13977-3.
72. “Knowledge into Action for Child Survival.” The Lancet 362, no. 9380 (n.d.): 323–27.
doi:10.1016/S0140-6736(03)13977-3.
73. Kt, Albert Aynsley-Green. “Translating Research into Political Advocacy to Improve Infant and
Child Health.” Early Human Development 90, no. 11 (November 2014): 761–64.
doi:10.1016/j.earlhumdev.2014.08.022.
74. Lawn, Joy E, Hannah Blencowe, Shefali Oza, Danzhen You, Anne CC Lee, Peter Waiswa, Marek
Lalli, et al. “Every Newborn: Progress, Priorities, and Potential beyond Survival.” The Lancet 384,
no. 9938 (July 2014): 189–205. doi:10.1016/S0140-6736(14)60496-7.
75. Lawn, Joy E, Simon Cousens, and Jelka Zupan. “4 Million Neonatal Deaths: When? Where?
Why?” The Lancet 365, no. 9462 (March 2005): 891–900. doi:10.1016/S0140-6736(05)71048-5.
76. Lawn, Joy E., Jon Rohde, Susan Rifkin, Miriam Were, Vinod K. Paul, and Mickey Chopra. “Alma-
Ata 30 Years on: Revolutionary, Relevant, and Time to Revitalise.” Lancet (London, England) 372,
no. 9642 (September 13, 2008): 917–27. doi:10.1016/S0140-6736(08)61402-6.
77. Leipziger, Danny, Marianne Fay, Quentin Wodon, and Tito Yepes. “Achieve Child Health Related
MDG: The Role of Infrastructure.” World Bank, 2003.
78. Levine, Orin S, David E Bloom, Thomas Cherian, Ciro de Quadros, Samba Sow, John Wecker,
Philippe Duclos, and Brian Greenwood. “The Future of Immunisation Policy, Implementation, and
Financing.” The Lancet 378, no. 9789 (July 2011): 439–48. doi:10.1016/S0140-6736(11)60406-6.
56 Mapping Global Leadership in Child Health
79. Liu, Li, Hope L Johnson, Simon Cousens, Jamie Perin, Susana Scott, Joy E Lawn, Igor Rudan, et
al. “Global, Regional, and National Causes of Child Mortality: An Updated Systematic Analysis for
2010 with Time Trends since 2000.” The Lancet 379, no. 9832 (June 2012): 2151–61.
doi:10.1016/S0140-6736(12)60560-1.
80. Liu, Li, Shefali Oza, Daniel Hogan, Jamie Perin, Igor Rudan, Joy E Lawn, Simon Cousens, Colin
Mathers, and Robert E Black. “Global, Regional, and National Causes of Child Mortality in 2000–
13, with Projections to Inform Post-2015 Priorities: An Updated Systematic Analysis.” The Lancet
385, no. 9966 (January 2015): 430–40. doi:10.1016/S0140-6736(14)61698-6.
81. Lozano, Rafael, Mohsen Naghavi, Kyle Foreman, Stephen Lim, Kenji Shibuya, Victor Aboyans,
Jerry Abraham, et al. “Global and Regional Mortality from 235 Causes of Death for 20 Age Groups
in 1990 and 2010: A Systematic Analysis for the Global Burden of Disease Study 2010.” The
Lancet 380, no. 9859 (December 2012): 2095–2128. doi:10.1016/S0140-6736(12)61728-0.
82. Lozano, Rafael, Haidong Wang, Kyle J Foreman, Julie Knoll Rajaratnam, Mohsen Naghavi, Jake R
Marcus, Laura Dwyer-Lindgren, et al. “Progress towards Millennium Development Goals 4 and 5
on Maternal and Child Mortality: An Updated Systematic Analysis.” The Lancet 378, no. 9797
(September 2011): 1139–65. doi:10.1016/S0140-6736(11)61337-8.
83. Lu, Chunling, Catherine M. Michaud, Emmanuela Gakidou, Kashif Khan, and Christopher J. L.
Murray. “Effect of the Global Alliance for Vaccines and Immunisation on Diphtheria, Tetanus, and
Pertussis Vaccine Coverage: An Independent Assessment.” Lancet (London, England) 368, no.
9541 (September 23, 2006): 1088–95. doi:10.1016/S0140-6736(06)69337-9.
84. Mangham, Lindsay J., and Kara Hanson. “Scaling up in International Health: What Are the Key
Issues?” Health Policy and Planning 25, no. 2 (March 1, 2010): 85–96. doi:10.1093/heapol/czp066.
85. Martines, Jose, Vinod K Paul, Zulfiqar A Bhutta, Marjorie Koblinsky, Agnes Soucat, Neff Walker,
Rajiv Bahl, Helga Fogstad, and Anthony Costello. “Neonatal Survival: A Call for Action.” The
Lancet 365, no. 9465 (March 2005): 1189–97. doi:10.1016/S0140-6736(05)71882-1.
86. Mason, Elizabeth, Lori McDougall, Joy E Lawn, Anuradha Gupta, Mariam Claeson, Yogan Pillay,
Carole Presern, et al. “From Evidence to Action to Deliver a Healthy Start for the next Generation.”
The Lancet 384, no. 9941 (August 2014): 455–67. doi:10.1016/S0140-6736(14)60750-9.
87. McCoy, David, Gayatri Kembhavi, Jinesh Patel, and Akish Luintel. “The Bill & Melinda Gates
Foundation’s Grant-Making Programme for Global Health.” The Lancet 373, no. 9675 (May 2009):
1645–53. doi:10.1016/S0140-6736(09)60571-7.
88. McGovern, Theresa. “No Risk, No Gain: Invest in Women and Girls by Funding Advocacy,
Organizing, Litigation and Work to Shift Culture.” Reproductive Health Matters 21, no. 42
(November 2013): 86–102. doi:10.1016/S0968-8080(13)42741-6.
89. Moon, Suerie, Nicole A. Szlezák, Catherine M. Michaud, Dean T. Jamison, Gerald T. Keusch,
William C. Clark, and Barry R. Bloom. “The Global Health System: Lessons for a Stronger
Page |
April 2016
57
Institutional Framework.” PLoS Med 7, no. 1 (January 26, 2010): e1000193.
doi:10.1371/journal.pmed.1000193.
90. Moroko Limited. “Independent Comprehensive Evaluation of the Scaling Up Nutrition
Movement,” May 2015.
91. Murray, Christopher J. L. “Shifting to Sustainable Development Goals--Implications for Global
Health.” The New England Journal of Medicine 373, no. 15 (October 8, 2015): 1390–93.
doi:10.1056/NEJMp1510082.
92. Mushi, Hildegalda P, Kethi Mullei, Janet Macha, Frank Wafula, Josephine Borghi, Catherine
Goodman, and Lucy Gilson. “The Challenges of Achieving High Training Coverage for IMCI:
Case Studies from Kenya and Tanzania.” Health Policy and Planning 26, no. 5 (September 2011):
395–404. doi:10.1093/heapol/czq068.
93. Pattinson, Robert, Kate Kerber, Eckhart Buchmann, Ingrid K Friberg, Maria Belizan, Sonia Lansky,
Eva Weissman, et al. “Stillbirths: How Can Health Systems Deliver for Mothers and Babies?” The
Lancet 377, no. 9777 (May 2011): 1610–23. doi:10.1016/S0140-6736(10)62306-9.
94. Pitt, Catherine, Giulia Greco, Timothy Powell-Jackson, and Anne Mills. “Countdown to 2015:
Assessment of Official Development Assistance to Maternal, Newborn, and Child Health, 2003–
08.” The Lancet 376, no. 9751 (October 2010): 1485–96. doi:10.1016/S0140-6736(10)61302-5.
95. Pitt, Catherine, Joy E. Lawn, Meghna Ranganathan, Anne Mills, and Kara Hanson. “Donor
Funding for Newborn Survival: An Analysis of Donor-Reported Data, 2002–2010.” PLOS Med 9,
no. 10 (October 30, 2012): e1001332. doi:10.1371/journal.pmed.1001332.
96. Piva, Paolo, and Rebecca Dodd. “Where Did All the Aid Go? An in-Depth Analysis of Increased
Health Aid Flows over the Past 10 Years.” Bulletin of the World Health Organization 87, no. 12
(December 1, 2009): 930–39. doi:10.2471/BLT.08.058677.
97. Powell-Jackson, Timothy, Josephine Borghi, Dirk H Mueller, Edith Patouillard, and Anne Mills.
“Countdown to 2015: Tracking Donor Assistance to Maternal, Newborn, and Child Health.” The
Lancet 368, no. 9541 (n.d.): 1077–87. doi:10.1016/S0140-6736(06)69338-0.
98. “Progress towards Millennium Development Goals 4 and 5 on Maternal and Child Mortality: An
Updated Systematic Analysis.” Accessed April 21, 2016. http://www.healthdata.org/research-
article/progress-towards-millennium-development-goals-4-and-5-maternal-and-child-mortality.
99. Pronyk, Paul M., Maria Muniz, Ben Nemser, Marie-Andrée Somers, Lucy McClellan, Cheryl A.
Palm, Uyen Kim Huynh, et al. “The Effect of an Integrated Multisector Model for Achieving the
Millennium Development Goals and Improving Child Survival in Rural Sub-Saharan Africa: A
Non-Randomised Controlled Assessment.” Lancet (London, England) 379, no. 9832 (June 9,
2012): 2179–88. doi:10.1016/S0140-6736(12)60207-4.
100. Rasanathan, Kumanan. “Policy Analysis—important for Improving iCCM Implementation;
Essential for Success of Global Health Efforts.” Health Policy and Planning 30, no. suppl 2
(December 1, 2015): ii1–2. doi:10.1093/heapol/czv097.
58 Mapping Global Leadership in Child Health
101. Rodríguez, Daniela C, Jessica Shearer, Alda RE Mariano, Pamela A Juma, Sarah L Dalglish, and
Sara Bennett. “Evidence-Informed Policymaking in Practice: Country-Level Examples of Use of
Evidence for iCCM Policy.” Health Policy and Planning 30, no. Suppl 2 (December 2015): ii36–
45. doi:10.1093/heapol/czv033.
102. Rohde, Jon, Simon Cousens, Mickey Chopra, Viroj Tangcharoensathien, Robert Black, Zulfiqar A
Bhutta, and Joy E Lawn. “30 Years after Alma-Ata: Has Primary Health Care Worked in
Countries?” The Lancet 372, no. 9642 (September 2008): 950–61. doi:10.1016/S0140-
6736(08)61405-1.
103. Rosato, Mikey, Glenn Laverack, Lisa Howard Grabman, Prasanta Tripathy, Nirmala Nair, Charles
Mwansambo, Kishwar Azad, et al. “Community Participation: Lessons for Maternal, Newborn, and
Child Health.” The Lancet 372, no. 9642 (September 2008): 962–71. doi:10.1016/S0140-
6736(08)61406-3.
104. Santosham, Mathuram, Aruna Chandran, Sean Fitzwater, Christa Fischer-Walker, Abdullah H
Baqui, and Robert Black. “Progress and Barriers for the Control of Diarrhoeal Disease.” The Lancet
376, no. 9734 (July 2010): 63–67. doi:10.1016/S0140-6736(10)60356-X.
105. Shiffman, Jeremy. “A Framework on Generating Attention for Global Health Issues: Case Study of
Maternal Survival.” Core Group Fall Meeting, September 15, 2010.
106. Shiffman, Jeremy. “A Social Explanation for the Rise and Fall of Global Health Issues.” Bulletin of
the World Health Organization 87, no. 8 (August 2009): 608–13.
107. Shiffman, Jeremy. “Issue Attention in Global Health: The Case of Newborn Survival.” The Lancet
375, no. 9730 (June 2010): 2045–49. doi:10.1016/S0140-6736(10)60710-6.
108. Shiffman, Jeremy. “Network Advocacy and the Emergence of Global Attention to Newborn
Survival.” Health Policy and Planning, September 24, 2015, czv092. doi:10.1093/heapol/czv092.
109. Shiffman, Jeremy, Kathryn Quissell, Hans Peter Schmitz, David L. Pelletier, Stephanie L. Smith,
David Berlan, Uwe Gneiting, et al. “A Framework on the Emergence and Effectiveness of Global
Health Networks.” Health Policy and Planning, August 29, 2015, czu046.
doi:10.1093/heapol/czu046.
110. Shiffman, Jeremy, and Stephanie Smith. “Generation of Political Priority for Global Health
Initiatives: A Framework and Case Study of Maternal Mortality.” The Lancet 370, no. 9595
(October 2007): 1370–79. doi:10.1016/S0140-6736(07)61579-7.
111. Sidibe, Michael, Ilavernil Ramiah, and Kent Buse. “The Global Fund at Five: What next for
Universal Access for HIV/AIDS, TB and Malaria?” ODI. Accessed November 16, 2015.
http://www.odi.org/publications/1348-global-fund-hiv-adis-tuberculosis-malaria.
112. Starrs, Ann, and Rotimi Sankore. “Momentum, Mandates, and Money: Achieving Health MDGs.”
The Lancet 375, no. 9730 (June 2010): 1946–48. doi:10.1016/S0140-6736(10)60841-0.
Page |
April 2016
59
113. Stevens, Gretchen A, Mariel M Finucane, Christopher J Paciorek, Seth R Flaxman, Richard A
White, Abigail J Donner, and Majid Ezzati. “Trends in Mild, Moderate, and Severe Stunting and
Underweight, and Progress towards MDG 1 in 141 Developing Countries: A Systematic Analysis
of Population Representative Data.” The Lancet 380, no. 9844 (September 2012): 824–34.
doi:10.1016/S0140-6736(12)60647-3.
114. Subhi, Rami, and Trevor Duke. “Leadership for Child Health in the Developing Countries of the
Western Pacific.” Journal of Global Health 1, no. 1 (June 2011): 96–104.
115. Swiss, Liam, Kathleen M. Fallon, and Giovani Burgos. “Does Critical Mass Matter? Women’s
Political Representation and Child Health in Developing Countries.” Social Forces, October 26,
2012, sos169. doi:10.1093/sf/sos169.
116. “The Trouble with the MDGs: Confronting Expectations of Aid and Development Success -
Working Paper 40.” Center For Global Development. Accessed October 17, 2015.
http://www.cgdev.org/publication/trouble-mdgs-confronting-expectations-aid-and-development-
success-working-paper-40.
117. “Transforming Our World: The 2030 Agenda for Sustainable Development .:. Sustainable
Development Knowledge Platform.” Accessed April 21, 2016.
https://sustainabledevelopment.un.org/post2015/transformingourworld.
118. Travis, Phyllida, Sara Bennett, Andy Haines, Tikki Pang, Zulfiqar Bhutta, Adnan A Hyder, Nancy
R Pielemeier, Anne Mills, and Timothy Evans. “Overcoming Health-Systems Constraints to
Achieve the Millennium Development Goals.” The Lancet 364, no. 9437 (September 2004): 900–
906. doi:10.1016/S0140-6736(04)16987-0.
119. Tulloch, J. “Integrated Approach to Child Health in Developing Countries.” Lancet (London,
England) 354 Suppl 2 (September 1999): SII16–20.
120. UNICEF. “A Promise Renewed Progress Report 2014.” UNICEF, September 2014.
121. UNIFEF. “Breastfeeding on the World Wide Agenda: Findings from a Landscape Analysis on
Political Commitment for Programmes to Protect, Promote and Support Breastfeeding,” April 2014.
https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=
0ahUKEwjD9d601Z_MAhWJ8x4KHd6YC_EQFggcMAA&url=http%3A%2F%2Fwww.unicef.or
g%2Feapro%2Fbreastfeeding_on_worldwide_agenda.pdf&usg=AFQjCNF-
hvFCi7D5yjOpgDX7obvvb9f5nw&sig2=jCGNKduuXFpZgTNUago4vQ&bvm=bv.119745492,d.d
mo.
122. UNICEF. “Committing to Child Survival. A Promise Renewed – Progress Report 2012.” UNICEF,
September 2012.
123. UNICEF. “Committing to Child Survival: A Promise Renewed, Progress Report 2015.” UNICEF,
September 2015.
124. UNICEF. “Global Strategy for Women’s, Children’s and Adolescents’ Health, 2016-2030: Survive,
Thrive, Transform,” May 2015. who.int/entity/pmnch/media/.../gs_pager.pdf?
60 Mapping Global Leadership in Child Health
125. UNICEF and WHO. “A Decade of Tracking Progress for Maternal, Newborn, and Child Survival:
The 2015 Report,” 2015.
126. UN IGME. “Levels and Trends of Child Mortality: Report 2015.” UNICEF, September 2015.
127. United Nations. “The Road to Dignity by 2030: Ending Poverty, Transforming All Lives and
Protecting the Planet Synthesis Report of the Secretary-General on the Post-2015 Sustainable
Development Agenda,” December 2014.
https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=
0ahUKEwiNgZP30Z_MAhXBpx4KHUHpAWsQFggdMAA&url=http%3A%2F%2Fwww.un.org
%2Fdisabilities%2Fdocuments%2Freports%2FSG_Synthesis_Report_Road_to_Dignity_by_2030.p
df&usg=AFQjCNEwkCJn7laJLLp3Hjoly7Yhjre3pQ&sig2=tnxSctcI6vbwovMo2R43Pg.
128. USAID. “Call to Action for Child Survival and Development,” June 2012.
129. Victora, Cesar G., Adam Wagstaff, Joanna Armstrong Schellenberg, Davidson Gwatkin, Mariam
Claeson, and Jean-Pierre Habicht. “Applying an Equity Lens to Child Health and Mortality: More
of the Same Is Not Enough.” Lancet (London, England) 362, no. 9379 (July 19, 2003): 233–41.
doi:10.1016/S0140-6736(03)13917-7.
130. Walker, Christa L Fischer, Igor Rudan, Li Liu, Harish Nair, Evropi Theodoratou, Zulfiqar A
Bhutta, Katherine L O’Brien, Harry Campbell, and Robert E Black. “Global Burden of Childhood
Pneumonia and Diarrhoea.” The Lancet 381, no. 9875 (n.d.): 1405–16. doi:10.1016/S0140-
6736(13)60222-6.
131. Walker, Neff, Gayane Yenokyan, Ingrid K Friberg, and Jennifer Bryce. “Patterns in Coverage of
Maternal, Newborn, and Child Health Interventions: Projections of Neonatal and under-5 Mortality
to 2035.” The Lancet 382, no. 9897 (n.d.): 1029–38. doi:10.1016/S0140-6736(13)61748-1.
132. Walley, John, Joy E. Lawn, Anne Tinker, Andres de Francisco, Mickey Chopra, Igor Rudan,
Zulfiqar A. Bhutta, Robert E. Black, and Lancet Alma-Ata Working Group. “Primary Health Care:
Making Alma-Ata a Reality.” Lancet (London, England) 372, no. 9642 (September 13, 2008):
1001–7. doi:10.1016/S0140-6736(08)61409-9.
133. Wang, Haidong, Chelsea A Liddell, Matthew M Coates, Meghan D Mooney, Carly E Levitz,
Austin E Schumacher, Henry Apfel, et al. “Global, Regional, and National Levels of Neonatal,
Infant, and under-5 Mortality during 1990–2013: A Systematic Analysis for the Global Burden of
Disease Study 2013.” The Lancet 384, no. 9947 (September 2014): 957–79. doi:10.1016/S0140-
6736(14)60497-9.
134. Wazny, Kerri, Salim Sadruddin, Alvin Zipursky, Davidson H. Hamer, Troy Jacobs, Karin
Kallander, Franco Pagnoni, et al. “Setting Global Research Priorities for Integrated Community
Case Management (iCCM): Results from a CHNRI (Child Health and Nutrition Research Initiative)
Exercise.” Journal of Global Health 4, no. 2 (December 2014): 020413.
doi:10.7189/jogh.04.020413.
Page |
April 2016
61
135. Were, Wilson M., Bernadette Daelmans, Zulfiqar Bhutta, Trevor Duke, Rajiv Bahl, Cynthia
Boschi-Pinto, Mark Young, Eric Starbuck, and Maharaj K. Bhan. “Children’s Health Priorities and
Interventions.” BMJ 351 (September 14, 2015): h4300. doi:10.1136/bmj.h4300.
136. Winch, Peter J., Karen Leban, Larry Casazza, Lynette Walker, and Karla Pearcy. “An
Implementation Framework for Household and Community Integrated Management of Childhood
Illness.” Health Policy and Planning 17, no. 4 (December 2002): 345–53.
137. World Bank. “Business Plan: Global Financing Facility in Support of Every Woman Every Child,”
June 2015.
138. Zar, Heather J. “Partnering with Centers of Excellence in High- and Low-Middle-Income
Countries: A Strategy to Strengthen Child Health Globally.” Pediatric Radiology 44, no. 6 (June
2014): 709–10. doi:10.1007/s00247-014-2906-3.
139. Zipursky, Alvin, Kerri Wazny, Robert Black, William Keenan, Christopher Duggan, Karen Olness,
Jonathan Simon, et al. “Global Action Plan for Childhood Diarrhoea: Developing Research
Priorities: Report from a Workshop of the Programme for Global Paediatric Research.” Journal of
Global Health 3, no. 1 (June 2013): 010406. doi:10.7189/jogh.03.010406.